Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Employer Coverage Under an Employer Group Health Plan Modified 2000 333 0 Form and Instruction RL-311F (08-22) Current Evidence of Coverage Under an Employee Group Health Plan
Form and Instruction RL-311F (XX-XX) Proposed Evidence of Coverage Under an Employee Group Health Plan
Medicare Modified 1840 245 0 Form and Instruction AA-6 (XX-XX) Proposed Employee Application for Medicare
Form and Instruction AA-7 (XX-XX) Proposed Spouse Divorced Spouse Application for Medicare
Form and Instruction AA-8 (XX-XX) Proposed Widow Widower Application for Medicare - Medical Insurance (Part B) Program
Form and Instruction AA-23 (XX-XX) Proposed Application for Medicare - Medical Insurance (Part B)
Form and Instruction AA-24 (XX-XX) Proposed Application for Medicare Part B - Exceptional Conditions
Form and Instruction AA-6 (01-18) Current Employee Application for Medicare
Form and Instruction AA-7 (01-18) Current Spouse Divorced Spouse Application for Medicare
Form and Instruction AA-8 (01-18) Current Widow Widower Application for Medicare - Medical Insurance (Part B) Program
Total burden requested under this ICR: 3840 578 0  
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