Information Collection

Application for Reimbursement for Hospital Services in Canada

IC 33891 under ICR 200806-3220-001 · OMB 3220-0086.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0086 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-104 (01-02) Application for Canadian Hospital Benefits Under Medicare - Part A Application for Reimbursement for Hospital Services in Canada	Form
Form AA-104 (proposed) Application for Canadian Hospital Benefits Under Medicare Part A Application for Reimbursement for Hospital Services in Canada	Form
AA-104 (01-02) Application for Canadian Hospital Benefits Under Medicar Form AA-104 (01-02).pdf	Form
AA-104 (proposed) Application for Canadian Hospital Benefits Under Medicar AA-104(xx-xx)proposed.pdf	Form

IC Title:

Application for Reimbursement for Hospital Services in Canada

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AA-104 (01-02)				No		Paper Only
Form	AA-104 (proposed)				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-20, Health Insurance and Medicare Medical Insurance Enrollment and Premium Payment System (Medicare) - RRB

FR Citation: 72 FR 73513

Number of Respondents: 35

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	35	-15	50
Annual IC Time Burden (Hours)	6	-2	8
Annual IC Cost Burden (Dollars)	0	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.

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