Information Collection

Medicare Physician Survey Form

IC 114076 under ICR 199308-0938-002 · OMB 0938-0615.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

MEDICARE PHYSICIAN SURVEY FORM

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA 412	No	No
Form	(FORMERLY	No	No
Form	HCFA-R-15)	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22,000	22,000
Annual IC Time Burden (Hours)	5,500	5,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.