Information Collection Request

Medicare Registration Summary and Medication History Personal Health Record Evaluation

ICR 200810-0938-016 · OMB 0938-1058 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS - 10264 CMS - PHR Survey General Form and Instruction New Available
Form CM-10264 CMs-10264 Survey Instrument Form and Instruction New Available
Form CM-10264 CMs-10264 Survey Instrument Form and Instruction New Available
CMS PHR OMB Statistical Methods Part B Revised.CLEAN.doc Supporting Statement B Uploaded 2009-04-10 Available
Attachment 2 - NORC BAA_PHR Evaluation.doc Supplementary Document Uploaded 2008-08-27 Available
CMS-10264 Supporting Statement A Revised.CLEAN.doc Supporting Statement A Uploaded 2009-04-10 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
188766 Medicare Registration Summary and Medication History Personal Health Record Evaluation (Discussion Group Burden) Form and Instruction NewCMS - PHR Survey General
187048 Medicare Registration Summary and Medication History Personal Health Record Evaluation (Health Plans) Form and Instruction NewCMs-10264 Survey Instrument
187047 Medicare Registration Summary and Medication History Personal Health Record Evaluation (Beneficiaries) Form and Instruction NewCMs-10264 Survey Instrument

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2012 36 Months From Approved
2,247 0 0
1,204 0 0
0 0 0





Reginfo record details
3
table that charts list of burden
IC Title Form No. Form Name
Medicare Registration Summary and Medication History Personal Health Record Evaluation (Beneficiaries) CM-10264
Medicare Registration Summary and Medication History Personal Health Record Evaluation (Discussion Group Burden) CMS - 10264
Medicare Registration Summary and Medication History Personal Health Record Evaluation (Health Plans) CM-10264

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,247 0 0 2,247 0 0
Annual Time Burden (Hours) 1,204 0 0 1,204 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No