Employer Coverage Under an Employer Group Health Plan

Medicare

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0082 can be found here:

Documents and Forms

Document Name Document Type
Form RL-311-F (03-10) Employer Coverage Under an Employer Group Health Plan Form and Instruction
RL-311-F (03-10) Evidence of Coverage Under an Employee Group Health Plan Form RL-311-F (03-10).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Employer Coverage Under an Employer Group Health Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 406 & 407

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	RL-311-F (03-10)	Evidence of Coverage Under an Employee Group Health Plan	Form RL-311-F (03-10).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-20, Health Insurance and Supplementary Medical Insurance Enrollment and Premium Payment System (MEDICARE)	FR Citation: 75 FR 43723

Number of Respondents: 800	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	133	133
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.