View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0245	ICR Reference No: 199610-0938-001
Status: Historical Active	Previous ICR Reference No: 199109-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Request for Enrollment in Supplementary Medical Insurance
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/16/1996
	Date Received in OIRA: 10/02/1996
Terms of Clearance: Approved for use through 11/99 under the condition that HCFA immediately incorporates into both the English and Spanish versions of this form the disclosure statements mandated by the Paperwork Reduction Act of 1995. HCFA must submit the amended forms to OMB for the public record.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/1999	11/30/1999
Responses	10,000	0	0
Time Burden (Hours)	2,500	0	0
Cost Burden (Dollars)	0	0	0

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