Information Collection

HA-67 with Medical Source Information - paper submission

IC 195760 under ICR 201009-0960-004 · OMB 0960-0722.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0722 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-67 Request for Medical Evidence From a Hospital HA-67 with Medical Source Information - paper submission	Form and Instruction
HA-67 Request for Medical Evidence From a Hospital HA-67 - Revised Version.pdf	Form and Instruction

IC Title:

HA-67 with Medical Source Information - paper submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	HA-67				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,060

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	67,320	67,320
Annual IC Time Burden (Hours)	16,830	16,830
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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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