Data Collection for the Second Generation Social Health Maintenance Organization Demonstration

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Collection for the Second Generation Social Health Maintenance Organization Demonstration	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 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 %

	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

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.