Information Collection

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

IC 187048 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 (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

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: 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 %

table that charts list of burden
	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

table that charts IC Documents
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.