Application for Reimbursement for Hospital Services in Canada

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form AA-104 (01-02) 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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AA-104 (01-02)	Application for Canadian Hospital Benefits Under Medicare - Part A	Form AA-104 (01-02).pdf		No		Paper Only
Form	AA-104 (proposed)	Application for Canadian Hospital Benefits Under Medicare Part A	AA-104(xx-xx)proposed.pdf		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 %

	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

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.