Request for Coverage Determination

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1212-0072 can be found here:

Documents and Forms

Document Name Document Type
Form Request for Covera Request for Coverage Determination Form
Coverage Determination Instructions.pdf Instruction
Request for Covera Request for Coverage Determination Coverage Determination Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Coverage Determination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Request for Coverage Determination	Request for Coverage Determination	Coverage Determination Form.pdf		Yes	Yes	Fillable Printable
Instruction			Coverage Determination Instructions.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 425	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	425	425
Annual IC Time Burden (Hours)	4,250	4,250
Annual IC Cost Burden (Dollars)	1,487,500	1,487,500

Documents for IC

Title	Document	Date Uploaded
No associated records found

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