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

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.