Information Collection

Internal Review Intake Form

IC 229533 under ICR 201712-3206-004 · OMB 3206-0263.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OPM 1840 Internal Review Intake Form	Form and Instruction
OPM 1840 MSP Program External Review Case Intake Form Current OPM Form 1840_2014_version.pdf	Form and Instruction
OPM 1840 MSP Program External Review Case Intake Form Revised OPM Form 1840_Highlighted Edits_2016_version.pdf	Form and Instruction
ExternalReviewIntakeForm_2016version_No Markups 1 25 17.pdf MSP Program External Review Case Intake Form w/o markups	IC Document

IC Title:

Agency IC Tracking Number:

OPM 1840

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 800.503a

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	OPM 1840	MSP Program External Review Case Intake Form	Current OPM Form 1840_2014_version.pdf		Yes	Yes	Fillable Printable
Form and Instruction	OPM 1840	MSP Program External Review Case Intake Form	Revised OPM Form 1840_Highlighted Edits_2016_version.pdf		Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title: Health Claims Disputes External Review Services OPM Central 16

FR Citation: 78 FR 65011

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MSP Program External Review Case Intake Form w/o markups	ExternalReviewIntakeForm_2016version_No Markups 1 25 17.pdf	12/21/2017

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