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

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 (Health Plans) Form and Instruction
CM-10264 CMs-10264 Survey Instrument Attachment 3 - CMS PHR survey final draft.pdf Form and Instruction
Attachment 2 - NORC BAA_PHR Evaluation.doc CMS-10264.Business Agreement IC Document

Information Collection (IC) Details

IC Title:	Medicare Registration Summary and Medication History Personal Health Record Evaluation (Health Plans)	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: 7	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7	7
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10264.Business Agreement	Attachment 2 - NORC BAA_PHR Evaluation.doc	08/27/2008

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