Request for Coverage Determination

Request for Coverage Determination

OMB: 1212-0072

IC ID: 236023

Information Collection (IC) Details

View Information Collection (IC)

Request for Coverage Determination
 
No New
 
Required to Obtain or Retain Benefits
 

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

Income Security General Retirement and Disability

 

425 0
   
Private Sector Businesses or other for-profits
 
   75 %

  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 425 0 425 0 0 0
Annual IC Time Burden (Hours) 4,250 0 4,250 0 0 0
Annual IC Cost Burden (Dollars) 1,487,500 0 1,487,500 0 0 0

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

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