OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Request for Medicare Payment

IC 44217 under ICR 202601-3220-003 · OMB 3220-0131.

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

View Information Collection (IC)

Request for Medicare Payment
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
42 CFR 405.424

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction G-740S (06-18) Patient's Request for Medicare Payment Form G-740S (06-18).pdf No   Paper Only
Form and Instruction CMS-1500 (02-12) Health Insurance Claim Form CMS 1500 (02-12).pdf Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

RRB-3, Medicare Part B   79 FR 58874

1 0
   
Individuals or Households
 
   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 1 0 0 0 0 1
Annual IC Time Burden (Hours) 1 0 0 0 0 1
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-1490S CMS-1490S (01-18).pdf 02/27/2019
CMS Workload Report CMS Workload Report October 2020-September 2021.pdf 09/20/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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