Request For Certification Of Medical Treatment By Attending Physician

REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN

OMB: 2900-0035

IC ID: 146658

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REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form FL21-104 No No


    

34,000 0
   
Individuals or Households
 
   0 %

  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 34,000 0 0 34,000 0 0
Annual IC Time Burden (Hours) 5,667 0 0 5,667 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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