Information Collection

Application for Reimbursement for Hospital Services in Canada

IC 33891 under ICR 201409-3220-001 · OMB 3220-0086.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-104 Application for Reimbursement for Hospital Services in Canada	Form
AA-104 Application for Canadian Hospital Benefits Under Medicar Form AA-104 (11-11).pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form	AA-104	Application for Canadian Hospital Benefits Under Medicare Part A	Form AA-104 (11-11).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 Medicare Medical Insurance Enrollment and Premium Payment System (Medicare) - RRB

FR Citation: 75 FR 43723

Number of Respondents: 30

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	30	-5	35
Annual IC Time Burden (Hours)	5	-1	6
Annual IC Cost Burden (Dollars)	0	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.