Claim for Reimbursement for Emergency Medical Care

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Reimbursement for Emergency Medical Care	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 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 %

	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

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.