Information Collection

Medicare Qualification Statement for Federal Employees and Supporting Regulations in 42 CFR 406.15

IC 8119 under ICR 200402-0938-008 · OMB 0938-0501.

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IC Title:

Medicare Qualification Statement for Federal Employees and Supporting Regulations in 42 CFR 406.15

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-565				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,300	0	4,300
Annual IC Time Burden (Hours)	717	-14	731
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Title	Document	Date Uploaded

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