Request for Medicare Payment

ICR 200908-3220-001

OMB: 3220-0131

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2009-09-23
IC Document Collections
IC ID
Document
Title
Status
44217 Modified
ICR Details
3220-0131 200908-3220-001
Historical Active 200607-3220-001
RRB
Request for Medicare Payment
Revision of a currently approved collection   No
Regular
Approved without change 11/12/2009
Retrieve Notice of Action (NOA) 09/25/2009
  Inventory as of this Action Requested Previously Approved
11/30/2012 36 Months From Approved 11/30/2009
1 0 1
1 0 1
0 0 0

The Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the Railroad Retirement System. The collection obtains the information needed by Palmetto GBA, the RRB's carrier, to pay claims for services covered under Part B of the program.

US Code: 45 USC 231f(d) Name of Law: Railroad Retirement Act
  
None

Not associated with rulemaking

  74 FR 36539 07/23/2009
74 FR 49046 09/25/2009
No

1
IC Title Form No. Form Name
Request for Medicare Payment G-740S (07-01), CMS-1500 (08-05), G-740s (proposed) Patient's Request for Medicare Payment ,   Patient's Request for Medicare Payment ,   Health Insurance Claim Form

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1 1 0 0 0 0
Annual Time Burden (Hours) 1 1 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
No
Uncollected
Charles Mierzwa 312-751-3363 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/25/2009


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