HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0204 can be found here:

Documents and Forms

Document Name Document Type
Form HRSA- 539 HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability Form and Instruction
HRSA- 539 Physician's Cert. of Borrower's Total and Permanent Disa REVform539.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HRSA- 539	Physician's Cert. of Borrower's Total and Permanent Disability	REVform539.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 177	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	245	-37	282
Annual IC Time Burden (Hours)	61	-10	71
Annual IC Cost Burden (Dollars)	0	-2,000	2,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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