HA-66 with Medical Source Information - paper submission

Request for Evidence from Doctor or Hospital

OMB: 0960-0722

IC ID: 9779

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HA-66 with Medical Source Information - paper submission
 
No Modified
 
Voluntary
 
20 CFR 416 Subpart I 20 CFR 404 Subpart P

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.pdf No   Paper Only

Income Security General Retirement and Disability

 

3,060 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 67,320 0 0 0 0 67,320
Annual IC Time Burden (Hours) 16,830 0 0 0 0 16,830
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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