Vocaional Rehabilitation Provider Claim - Claiming Reimbursement SSA-199

Vocational Rehabilitation Provider Claim

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0310 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-199 Vocaional Rehabilitation Provider Claim - Claiming Reimbursement SSA-199 Form
Revised Privacy Act Statement - SSA-199.pdf Other-Revised Privacy Act Statement
SSA-199 - Portal Screens.pdf Other-Portal Screens
SSA-199 Vocational Rehabilitation Provider Claim SSA-199 - Revised Version.pdf Form
SSA-199 - Current Version.pdf Current SSA-199 IC Document

Information Collection (IC) Details

IC Title:	Vocaional Rehabilitation Provider Claim - Claiming Reimbursement SSA-199	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 416.2208(b) 20 CFR 404.2108(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-199	Vocational Rehabilitation Provider Claim	SSA-199 - Revised Version.pdf	Yes	No	Fillable Printable
Other-Revised Privacy Act Statement			Revised Privacy Act Statement - SSA-199.pdf	Yes	No	Printable Only
Other-Portal Screens			SSA-199 - Portal Screens.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	12,800	12,800
Annual IC Time Burden (Hours)	4,907	4,907
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-199	SSA-199 - Current Version.pdf	02/18/2019

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