OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Claim for Reimbursement for Emergency Medical Care

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Claim for Reimbursement for Emergency Medical Care
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

General Government Executive Functions

 

1 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1 0 0 0 0 1
Annual IC Time Burden (Hours) 1 0 0 0 0 1
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.