Medicare Registration Summary and Medication History Personal Health Record Evaluation (Discussion Group Burden)

Medicare Registration Summary and Medication History Personal Health Record Evaluation

Documents and Forms

Document Name Document Type
Form CMS - 10264 Medicare Registration Summary and Medication History Personal Health Record Evaluation (Discussion Group Burden) Form and Instruction
CMS - 10264 CMS - PHR Survey General CMS PHR survey_general.FINAL.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Registration Summary and Medication History Personal Health Record Evaluation (Discussion Group Burden)	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	CMS - 10264	CMS - PHR Survey General	CMS PHR survey_general.FINAL.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	80	80
Annual IC Time Burden (Hours)	120	120
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.