Information Collection

Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)

IC 179019 under ICR 201703-0960-008 · OMB 0960-0555.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0555 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CE_c) Report to Med Provider - Revised.pdf	Other-Sample of state DDS Claimant R
CE_c) Report to Med Provider - Current.pdf CE_c) Report to Med Provider - Current	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1614 20 CFR 404.1518(c) 20 CFR 404.1613 20 CFR 404.1624 20 CFR 416.903a 20 CFR 416.1024 20 CFR 416.912 20 CFR 416.913 20 CFR 416.914 20 CFR 416.917 20 CFR 416.919 20 CFR 416.1013 20 CFR 416.1014 20 CFR 404.1503a 20 CFR 404.1513 20 CFR 404.1514 20 CFR 404.1512 20 CFR 404.1517 20 CFR 404.1519 20 CFR 416.918(c)

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-Sample of state DDS Claimant Report Letter/Form			CE_c) Report to Med Provider - Revised.pdf		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 450,000

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	Previously Approved
Annual Number of Responses for this IC	450,000	450,000
Annual IC Time Burden (Hours)	37,500	37,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CE_c) Report to Med Provider - Current	CE_c) Report to Med Provider - Current.pdf	06/13/2017

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