Information Collection

HA-67 with Medical Source Information - paper submission

IC 195760 under ICR 201703-0960-014 · OMB 0960-0722.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0722 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-67 HA-67 with Medical Source Information - paper submission	Form and Instruction
HA-67 Request for Medical Evidence From a Hospital HA-67 - Revised Version.pdf	Form and Instruction
HA-67 - Current Version.pdf Current HA-67	IC Document

IC Title:

HA-67 with Medical Source Information - paper submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404, Subpart P 20 CFR 416, Subpart I (To search for a specific CFR, visit the Code of Federal Regulations.)

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 and Instruction	HA-67	Request for Medical Evidence From a Hospital	HA-67 - Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,060

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	67,320	67,320
Annual IC Time Burden (Hours)	16,830	16,830
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-67	HA-67 - Current Version.pdf	07/11/2017

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