Application for Reimbursement for Hospital Services in Canada

ICR 200506-3220-002

OMB: 3220-0086

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
3220-0086 200506-3220-002
Historical Active 200205-3220-004
RRB
Application for Reimbursement for Hospital Services in Canada
Extension without change of a currently approved collection   No
Regular
Approved without change 08/03/2005
Retrieve Notice of Action (NOA) 06/08/2005
  Inventory as of this Action Requested Previously Approved
08/31/2008 08/31/2008 08/31/2005
50 0 50
8 0 8
0 0 0

The Railroad Retirement Board administers the Medicare program for persons covered by the Railroad Retirement system. The collection obtains the information needed to determine eligibility for and the amount due for covered hosptial services received in Canada.

None
None


No

1
IC Title Form No. Form Name
Application for Reimbursement for Hospital Services in Canada AA-104

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 50 50 0 0 0 0
Annual Time Burden (Hours) 8 8 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/08/2005


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