Information Collection

Medicare Part B Online Application - COVID-related

IC 241722 under ICR 202103-0960-010 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA Medicare Part B Online Application.pdf	Other-Internet Screens for COVID0-re
Application for Enrollment in Medicare Part B (Medical Insurance) Under a Special Enrollment Period - Webform.pdf	Other-Webform Version

IC Title:

Medicare Part B Online Application - COVID-related

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.601 - 404.603

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-10,000	10,000
Annual IC Time Burden (Hours)	-5,000	5,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.