Information Collection

Request for Evidence from Doctor or Hospital

IC 9779 under ICR 200708-0960-005 · OMB 0960-0722.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0722 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-67 Request for Evidence from Doctor or Hospital	Form
HA-67 Request for Evidence from Hospital HA-67.pdf eme.ssa.gov	Form
HA-66 Request for Evidence from Doctor HA-66.pdf eme.ssa.gov	Form
Medical Source Bil Medical Source Billing Form Medical Source Billing Info.doc	Form
PRA statement.doc PRA Statement	IC Document

IC Title:

Request for Evidence from Doctor or Hospital

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404 Subpart P 20 CFR 416 Subpart 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	HA-67	Request for Evidence from Hospital	HA-67.pdf	http://eme.ssa.gov	Yes	Yes	Fillable Fileable
Form	HA-66	Request for Evidence from Doctor	HA-66.pdf	http://eme.ssa.gov	Yes	Yes	Fillable Fileable
Form	Medical Source Billing Form	Medical Source Billing Form	Medical Source Billing Info.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: 20,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	400,000	400,000
Annual IC Time Burden (Hours)	100,000	100,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PRA Statement	PRA statement.doc	01/23/2008

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