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Federal forms, ICRs, and supporting documents

Information Collection

Request for Review of Part B Medicare Claim

IC 33905 under ICR 200210-3220-002 · OMB 3220-0100.

Documents and Forms
Document Name
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Information Collection (IC) Details

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Request for Review of Part B Medicare Claim
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form G-790 No No
Form G-791 No No


    

4,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,100 0 0 0 0 4,100
Annual IC Time Burden (Hours) 1,025 0 0 0 0 1,025
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
 
 
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.