HA-67 with Medical Source Information - paper submission

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⚠️ Notice: This information collection may be referencing outdated material.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 HA-67 with Medical Source Information - paper submission Form and Instruction
HA-67 Request for Medical Evidence From a Hospital HA-67 - Revised Version.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	HA-67 with Medical Source Information - paper submission	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HA-67	Request for Medical Evidence From a Hospital	HA-67 - Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,060	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	67,320	67,320
Annual IC Time Burden (Hours)	16,830	16,830
Annual IC Cost Burden (Dollars)	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.