Information Collection

Statement Regarding Patient's Capability to Manage Payments

IC 179885 under ICR 202303-3220-001 · OMB 3220-0052.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0052 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-478 Statement Regarding Patient's Capability to Manage Payments	Form and Instruction
G-478 Statement Regarding Patient's Capability to Manage Payme Form G-478 (03-17).pdf	Form and Instruction
G-478 Statement Regarding Patient's Capability to Manage Payme Form G-478 (03-17).pdf	Form and Instruction
G-478 (xx-xx) Statement Regarding Patient's Capability to Manage Payme Form G-478 (XX-XX) Proposed.pdf	Form and Instruction
G-478 (xx-xx) Statement Regarding Patient's Capability to Manage Payme Form G-478 (XX-XX) Proposed.pdf	Form and Instruction
Form SSA-787 (05-10).pdf SSA-787 (05-2010)	IC Document
Form SSA-787 (05-10).pdf SSA-787 (05-2010)	IC Document

IC Title:

Statement Regarding Patient's Capability to Manage Payments

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 266.3(b)

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
Form and Instruction	G-478	Statement Regarding Patient's Capability to Manage Payments	Form G-478 (03-17).pdf		No		Paper Only
Form and Instruction	G-478 (xx-xx)	Statement Regarding Patient's Capability to Manage Payments	Form G-478 (XX-XX) Proposed.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-787 (05-2010)	Form SSA-787 (05-10).pdf	08/22/2016

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