Information Collection

Treating Physician Consultative Examination Interest Form

IC 179601 under ICR 201002-0960-012 · OMB 0960-0751.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-84 Treating Physician Consultative Examination Interest Form	Form
SSA-84 Treating Physician Consultative Examination Interest For SSA-84 (new).pdf	Form
SSA-84 (6).docx Treating Physician Consultative Examination Interest Form (Currently Used)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1519g-i

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	SSA-84	Treating Physician Consultative Examination Interest Form	SSA-84 (new).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 168

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Treating Physician Consultative Examination Interest Form (Currently Used)	SSA-84 (6).docx	05/13/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.