Information Collection

Claim for Reimbursement for Emergency Medical Care

IC 35554 under ICR 200807-3240-018 · OMB 3240-0030.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSS FORM 166 Claim for Reimbursement for Emergency Medical Care	Form and Instruction
SSS FORM 166 Claim Reimbursement for Emergency Medical Care SSS FORM 166.pdf	Form and Instruction

IC Title:

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 and Instruction	SSS FORM 166	Claim Reimbursement for Emergency Medical Care	SSS FORM 166.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
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.