Information Collection

Request For Medicare Payment

IC 162193 under ICR 198710-9999-001 · OMB 9999-0011.

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	REQUEST FOR MEDICARE PAYMENT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	G-740B	No	No
Form	G-740S	No	No
Form	HCFA-1500	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	8,499,999	8,499,999
Annual IC Time Burden (Hours)	1,080,523	1,080,523
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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