OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Claimant's Recent Medical Treatment

IC 9198 under ICR 202105-0960-009 · OMB 0960-0292.

Documents and Forms
Document Name
Document Type
Form
Form
Other-Revised Privacy Act Statement
Other-Revised Privacy Act Statement
Other-Paper Reduction Act Statement
Other-Paper Reduction Act Statement
Form
Form
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Claimant's Recent Medical Treatment
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.1512 20 CFR 416.912

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HA-4631 Claimant's Recent Medical Treatment HA-4631 (revised).pdf http://www.ssa.gov/online/ha-4631.html. Yes Yes Fillable Fileable Signable
Other-Revised Privacy Act Statement Privacy Act Statement 0292 (revised).docx www.ssa.gov Yes No Printable Only
Other-Paper Reduction Act Statement revised PRA 0292 (revised).docx No   Paper Only

Income Security General Retirement and Disability

 

51,000 0
   
Individuals or Households
 
   80 %

  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 51,000 0 0 -149,000 0 200,000
Annual IC Time Burden (Hours) 71,400 0 0 38,067 0 33,333
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
HA-4631 Current Version HA-4631(current).pdf 06/30/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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