PRA IC List
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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Employer Coverage Under an Employer Group Health Plan
Modified
800
133
0
Form and Instruction
RL-311-F (03-10)
Evidence of Coverage Under an Employee Group Health Plan
Medicare
Unchanged
240
32
0
Form and Instruction
AA-6 (01-03)
Employee Application for Medicare
Form and Instruction
AA-7 (01-03)
Spouse/Divorced Spouse Application for Medicare
Form and Instruction
AA-8 (01-03)
Widow/Widower Application for Medicare
Total burden requested under this ICR:
1040
165
0
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