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Request for Medicare Payment
Request for Medicare Payment
OMB: 3220-0131
IC ID: 44217
OMB.report
RRB
OMB 3220-0131
ICR 200908-3220-001
IC 44217
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0131 can be found here:
2022-09-21 - Extension without change of a currently approved collection
2019-04-30 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form G-740S (07-01)
Request for Medicare Payment
Form and Instruction
G-740S (07-01) Patient's Request for Medicare Payment
G-740S (07-01).pdf
Form and Instruction
G-740s (proposed) Patient's Request for Medicare Payment
G-740s proposed.pdf
Form and Instruction
CMS-1500 (08-05) Health Insurance Claim Form
CMS-1500 (08-05).pdf
Form and Instruction
CMS-1490S (1-2005).pdf
CMS-1490S
IC Document
CMS Workload Report.pdf
CMS Workload Report
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Request for Medicare Payment
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 405.424
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
G-740S (07-01)
Patient's Request for Medicare Payment
G-740S (07-01).pdf
No
Paper Only
Form and Instruction
CMS-1500 (08-05)
Health Insurance Claim Form
CMS-1500 (08-05).pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
G-740s (proposed)
Patient's Request for Medicare Payment
G-740s proposed.pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
RRB-3, Medicare Part B
FR Citation:
72 FR 73502
Number of Respondents:
1
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
1
0
0
0
0
1
Annual IC Time Burden (Hours)
1
0
0
0
0
1
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CMS-1490S
CMS-1490S (1-2005).pdf
09/23/2009
CMS Workload Report
CMS Workload Report.pdf
09/23/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.