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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 187047 under ICR 200810-0938-016 · OMB 0938-1058.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Medicare Registration Summary and Medication History Personal Health Record Evaluation (Beneficiaries)
 
No New
 
Voluntary
 

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

Health Health Care Services

 

2,160 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,160 0 2,160 0 0 0
Annual IC Time Burden (Hours) 1,080 0 1,080 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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