Information Collection

HA-66 with Medical Source Information - paper submission

IC 9779 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⚠️ Notice: This information collection may be referencing outdated material.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-66 HA-66 with Medical Source Information - paper submission	Form and Instruction
HA-66 Request for Medical Evidence From a Doctor HA-66 - Revised Version.pdf	Form and Instruction
HA-66 - Current Version.pdf Current HA-66	IC Document

IC Title:

HA-66 with Medical Source Information - paper submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404 Subpart P 20 CFR 416 Subpart 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 and Instruction	HA-66	Request for Medical Evidence From a Doctor	HA-66 - Revised Version.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: 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	Previously Approved
Annual Number of Responses for this IC	67,320	-332,680	400,000
Annual IC Time Burden (Hours)	16,830	-83,170	100,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-66	HA-66 - Current Version.pdf	03/10/2011

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