Medicare Registration Summary and Medication History Personal Health Record Evaluation (Beneficiaries)

Medicare Registration Summary and Medication History Personal Health Record Evaluation

Documents and Forms

Document Name Document Type
Form CM-10264 Medicare Registration Summary and Medication History Personal Health Record Evaluation (Beneficiaries) Form and Instruction
CM-10264 CMs-10264 Survey Instrument Attachment 3 - CMS PHR survey final draft.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Registration Summary and Medication History Personal Health Record Evaluation (Beneficiaries)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	CM-10264	CMs-10264 Survey Instrument	Attachment 3 - CMS PHR survey final draft.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,160	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,160	2,160
Annual IC Time Burden (Hours)	1,080	1,080
Annual IC Cost Burden (Dollars)	0	0

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.