OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Internal Review Intake Form

IC 229533 under ICR 201712-3206-004 · OMB 3206-0263.

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

View Information Collection (IC)

Internal Review Intake Form OPM 1840
 
No New
 
Required to Obtain or Retain Benefits
 
45 CFR 800.503a

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OPM 1840 MSP Program External Review Case Intake Form Current OPM Form 1840_2014_version.pdf Yes Yes Fillable Printable
Form and Instruction OPM 1840 MSP Program External Review Case Intake Form Revised OPM Form 1840_Highlighted Edits_2016_version.pdf Yes Yes Fillable Printable

General Government Central Personnel

Health Claims Disputes External Review Services OPM Central 16  78 FR 65011

800 0
   
Individuals or Households
 
   100 %

  Approved 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 800 0 800 0 0 0
Annual IC Time Burden (Hours) 800 0 800 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
MSP Program External Review Case Intake Form w/o markups ExternalReviewIntakeForm_2016version_No Markups 1 25 17.pdf 12/21/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.