Information Collection

HA-66 with Medical Source Information - paper submission

IC 9779 under ICR 202605-0960-001 · OMB 0960-0722.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-66 Request for Medical Evidence From a Doctor HA-66 with Medical Source Information - paper submission	Form and Instruction
HA-66 Request for Medical Evidence From a Doctor HA-66 (revised).pdf	Form and Instruction
HA-66 (current).pdf HA-66 (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416 Subpart I 20 CFR 404 Subpart P

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	HA-66				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,843

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	150,546	83,226	67,320
Annual IC Time Burden (Hours)	37,637	20,807	16,830
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HA-66 (current)		05/04/2026

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

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