Information Collection

Functionality for Electronic Medical Provide Reimbursement Requests

IC 189280 under ICR 201202-0960-003 · OMB 0960-0753.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0753 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ERE Medical Provider Screen Shots -- 0960-0753.doc	Other-Elctronic Payment Request Scre

IC Title:

Functionality for Electronic Medical Provide Reimbursement Requests

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
Other-Elctronic Payment Request Screens			ERE Medical Provider Screen Shots -- 0960-0753.doc	http://www.socialsecurity.gov (exact link to be estalished right before it goes live)	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,000

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: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-13,000	13,000
Annual IC Time Burden (Hours)	-2,167	2,167
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.