OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Statement Regarding Patient's Capability to Manage Payments

IC 179885 under ICR 202507-3220-004 · OMB 3220-0052.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Statement Regarding Patient's Capability to Manage Payments
 
No Modified
 
Voluntary
 
20 CFR 266.3(b)

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 (07-23) - Current.pdf No   Paper Only
Form and Instruction G-478 (xx-xx) Statement Regarding Patient's Capability to Manage Payments G-478 (XX-XX) - Proposed.pdf No   Paper Only

Income Security General Retirement and Disability

RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System   79 FR 58874

2,000 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Requested 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 2,000 0 0 0 0 2,000
Annual IC Time Burden (Hours) 200 0 0 0 0 200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
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