Information Collection

Additional Surgeon and Physician Request Form

IC 256998 under ICR 202502-0915-003 · OMB 0915-0184.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0184 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 20 Additional Surgeon and Physician Request Form	Form and Instruction
Form 20 Additional Surgeon and Physician Request Form Additional Surgeon and Physician Request Form	Form and Instruction
Form 20S (Revised 03.25 Additional Surgeon and Physician Request Form Additional Surgeon and Physician Request Form	Form and Instruction
20 Additional Surgeon and Physician Request Form Additional Surgeon and Physician Request Form.docx	Form and Instruction
20 Additional Surgeon and Physician Request Form Additional Surgeon and Physician Request Form.docx	Form and Instruction
20S (Revised 03.25 Additional Surgeon and Physician Request Form S_HSB_0915-0184_Additional Surgeon and Physician Request Form REDLINE.docx	Form and Instruction
20S (Revised 03.25 Additional Surgeon and Physician Request Form S_HSB_0915-0184_Additional Surgeon and Physician Request Form REDLINE.docx	Form and Instruction

IC Title:

Additional Surgeon and Physician Request Form

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:

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	20				Yes	Yes	Fillable Fileable
Form and Instruction	20S (Revised 03.25)				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,562

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	125	125
Annual IC Time Burden (Hours)	146	146
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.

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