Claimant's Recent Medical Treatment

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0292 can be found here:

Documents and Forms

Document Name Document Type
Form HA-4631 Claimant's Recent Medical Treatment Form
HA-4631 CLAIMANT'S RECENT MEDICAL TREATMENT HA-4631 (from DGS) revised.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claimant's Recent Medical Treatment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.912 20 CFR 404.1512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-4631	CLAIMANT'S RECENT MEDICAL TREATMENT	HA-4631 (from DGS) revised.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	350,000	30,000	320,000
Annual IC Time Burden (Hours)	58,333	5,000	53,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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