Request for Evidence from Doctor or Hospital

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0722 can be found here:

Documents and Forms

Document Name Document Type
Form HA-67 Request for Evidence from Doctor or Hospital Form
HA-67 Request for Evidence from Hospital HA-67.pdf eme.ssa.gov Form
HA-66 Request for Evidence from Doctor HA-66.pdf eme.ssa.gov Form
Medical Source Bil Medical Source Billing Form Medical Source Billing Info.doc Form
PRA statement.doc PRA Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Evidence from Doctor or Hospital	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404 Subpart P 20 CFR 416 Subpart I

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-67	Request for Evidence from Hospital	HA-67.pdf	http://eme.ssa.gov	Yes	Yes	Fillable Fileable
Form	HA-66	Request for Evidence from Doctor	HA-66.pdf	http://eme.ssa.gov	Yes	Yes	Fillable Fileable
Form	Medical Source Billing Form	Medical Source Billing Form	Medical Source Billing Info.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Previously Approved
Annual Number of Responses for this IC	400,000	400,000
Annual IC Time Burden (Hours)	100,000	100,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
PRA Statement	PRA statement.doc	01/23/2008

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