Request for Coverage Determination

Documents and Forms

Document Name Document Type
Form Form 1 Request for Coverage Determination Form
Coverage Determination Instructions 2025.02.pdf Instruction
Form 1 Request for Coverage Determination Coverage Determination Form 2025.04.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Coverage Determination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form 1	Request for Coverage Determination	Coverage Determination Form 2025.04.pdf		Yes	Yes	Fillable Fileable Signable
Instruction			Coverage Determination Instructions 2025.02.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 295	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	295	-15	310
Annual IC Time Burden (Hours)	443	-22	465
Annual IC Cost Burden (Dollars)	88,500	-4,500	93,000

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.