Information Collection

Data Collection for the Second Generation Social Health Maintenance Organization Demonstration

IC 8352 under ICR 200702-0938-006 · OMB 0938-0709.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-204 Data Collection for the Second Generation Social Health Maintenance Organization Demonstration	Form and Instruction
CMS-R-204 Second Generation Social HMO Organization Demonstration CMS-R-204-Initial Interview-q1r.doc	Form and Instruction
CMS-R-204-(SHMOBaseLet-Form1(CMSrvsd-01-05).doc Base Letter	IC Document
CMS-R-204-(SHMOfupLet-Form1(CMSrvsd-01-05).doc Follow-up Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-204	Second Generation Social HMO Organization Demonstration	CMS-R-204-Initial Interview-q1r.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,624

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	17,624	2,624	15,000
Annual IC Time Burden (Hours)	3,525	525	3,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Base Letter	CMS-R-204-(SHMOBaseLet-Form1(CMSrvsd-01-05).doc
Follow-up Letter	CMS-R-204-(SHMOfupLet-Form1(CMSrvsd-01-05).doc

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