Medicare

ICR 202411-3220-012

OMB: 3220-0082

Federal Form Document

Forms and Documents

Document Name	Status
Form AA-6 (XX-XX) Propo Medicare Form and Instruction	Modified
Form RL-311F (08-22) Cu Employer Coverage Under an Employer Group Health Plan Form and Instruction	Modified
3220-0082_Final.docx Supporting Statement A	2025-04-02
Request OMB Approval of NonSubstatative Change to ICR 3220-0082_Signed.pdf Justification for No Material/Nonsubstantive Change	2022-06-08
CMS-L564(8-20).pdf Supplementary Document	2021-06-29
Form G-346 (03-18).pdf Supplementary Document	2018-04-17
Form RL-9 (07-02).pdf Supplementary Document	2015-01-08
Form RB-20 (01-18).pdf Supplementary Document	2018-04-17
Form RB-3 (11-08).pdf Supplementary Document	2015-01-08

IC Document Collections

IC ID	Document Title	Status
33882	Medicare Form and Instruction	Modified
186948	Employer Coverage Under an Employer Group Health Plan Form and Instruction	Modified