OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Part B Online Application - COVID-related

IC 241722 under ICR 202101-0960-004 · OMB 0960-0618.

Documents and Forms
Document Name
Document Type
Other-Internet Screens for COVID0-re
Other-Internet Screens for COVID0-re
Other-Webform Version
Other-Webform Version
Information Collection (IC) Details

View Information Collection (IC)

Medicare Part B Online Application - COVID-related
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
20 CFR 404.601 - 404.603

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Internet Screens for COVID0-related collection SSA Medicare Part B Online Application.pdf Yes Yes Fillable Fileable Signable
Other-Webform Version Application for Enrollment in Medicare Part B (Medical Insurance) Under a Special Enrollment Period - Webform.pdf Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

10,000 0
   
Individuals or Households
 
   100 %

  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 10,000 0 0 0 0 10,000
Annual IC Time Burden (Hours) 5,000 0 0 0 0 5,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.