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Application for Reimbursement for Hospital Services in Canada
Application for Reimbursement for Hospital Services in Canada
OMB: 3220-0086
IC ID: 33891
OMB.report
RRB
OMB 3220-0086
ICR 201409-3220-001
IC 33891
( )
Documents and Forms
Document Name
Document Type
Form AA-104
Application for Reimbursement for Hospital Services in Canada
Form
AA-104 Application for Canadian Hospital Benefits Under Medicar
Form AA-104 (11-11).pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Application for Reimbursement for Hospital Services in Canada
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
AA-104
Application for Canadian Hospital Benefits Under Medicare Part A
Form AA-104 (11-11).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-20, Health Insurance and Medicare Medical Insurance Enrollment and Premium Payment System (Medicare) - RRB
FR Citation:
75 FR 43723
Number of Respondents:
30
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
30
0
0
-5
0
35
Annual IC Time Burden (Hours)
5
0
0
-1
0
6
Annual IC Cost Burden (Dollars)
0
0
0
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.
