Information Collection

Medical Travel Refund Request

IC 224888 under ICR 201612-1240-006 · OMB 1240-0056.

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Medical Travel Refund Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.404 20 CFR 725.406 20 CFR 10.315 20 CFR 725.701

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 342,452	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	342,452	342,452
Annual IC Time Burden (Hours)	56,849	56,849
Annual IC Cost Burden (Dollars)	171,123	171,123

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