Information Collection

Treating Physician Consultative Examination Interest Form

IC 179601 under ICR 200704-0960-009 · OMB 0960-0751.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0751 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-84 Treating Physician Consultative Examination Interest Form Form
SSA-84 Treating Physician Consultative Examination Interest For SSA-84.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Treating Physician Consultative Examination Interest Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1519g-i

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-84	Treating Physician Consultative Examination Interest Form	SSA-84.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 168	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

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.