OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Claimant's Recent Medical Treatment

IC 9198 under ICR 201801-0960-004 · OMB 0960-0292.

Documents and Forms
Document Name
Document Type
Form
Other-Revised Privacy Act Statement
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Claimant's Recent Medical Treatment
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.1512 20 CFR 416.912

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HA-4631 Claimant's Recent Medical Treatment HA-4631 - Revised Version.pdf http://www.ssa.gov/online/ha-4631.html. Yes Yes Fillable Fileable Signable
Other-Revised Privacy Act Statement HA-4631 - Revised PA Statement.pdf www.ssa.gov Yes No Printable Only

Income Security General Retirement and Disability

 

200,000 0
   
Individuals or Households
 
   80 %

  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 200,000 0 0 0 0 200,000
Annual IC Time Burden (Hours) 33,333 0 0 0 0 33,333
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
HA-4631 Current Version HA-4631 - Current Version.pdf 04/10/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.