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Request for Retirement Benefit Informatin
Medicare Request for Retirement Benefit Information (CMS-R-285)
OMB: 0938-0769
IC ID: 8511
OMB.report
HHS/CMS
OMB 0938-0769
ICR 202408-0938-005
IC 8511
( )
Documents and Forms
Document Name
Document Type
Form CMS-R-285
Request for Retirement Benefit Informatin
Form
CMS-R-285 Request for Retirement Benefit Information
CMS-R285 Updated_508.pdf
Form
CMS-R-285 Request for Retirement Benefit Information
CMS-R285 Updated_508.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Request for Retirement Benefit Informatin
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-R-285
Request for Retirement Benefit Information
CMS-R285 Updated_508.pdf
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
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
500
0
0
0
500
0
Annual IC Time Burden (Hours)
125
0
0
0
125
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.
