Information Collection

Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority & Invoice for Travel by Ambulance or other Hired Vehicle; Authorization & Invoice for Medical....

IC 42186 under ICR 200203-2900-014 · OMB 2900-0080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0080 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority & Invoice for Travel by Ambulance or other Hired Vehicle; Authorization & Invoice for Medical....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	10-2065	No	No
Form	10-7078	No	No
Form	10-583	No	No
Form	10-2511	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 480,100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	480,100	480,100
Annual IC Time Burden (Hours)	32,742	32,742
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.