HA-66 with Medical Source Information - electronic submission

Request for Evidence from Doctor or Hospital

OMB: 0960-0722

IC ID: 195758

Documents and Forms
Document Name
Document Type
Other-Internet Screen
Information Collection (IC) Details

View Information Collection (IC)

HA-66 with Medical Source Information - electronic submission
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Internet Screen HA-66 & HA-67 Electronic Screen.pdf Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

8,940 0
   
Individuals or Households
 
   100 %

  Approved 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 196,680 0 0 196,680 0 0
Annual IC Time Burden (Hours) 49,170 0 0 49,170 0 0
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.

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