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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
ERE Medical Provider Screen Shots -- 0960-0753.doc www.socialsecurity.gov (exact link to be estalished right before it goes live) Other-Elctronic Payment Request Scre

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.