Request for Medicare Payment

Request for Medicare Payment

OMB: 3220-0131

IC ID: 44217

Information Collection (IC) Details

View Information Collection (IC)

Request for Medicare Payment
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 405.424

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1500 (02-12) Health Insurance Claim Form CMS 1500 (02-12).pdf Yes Yes Fillable Fileable Signable
Form and Instruction G-740S (03-13) Patient's Request for Medicare Payment Form G-740S (03-13).pdf No   Paper Only

Income Security General Retirement and Disability

RRB-3, Medicare Part B   79 FR 58874

1 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 1 0 0 0 0 1
Annual IC Time Burden (Hours) 1 0 0 0 0 1
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-1490S CMS-1490S (1-2005).pdf 09/23/2009
CMS Workload Report CMS Workload Report 2014-2015.pdf 03/25/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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