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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.