Information Collection

Office-based Physicians eligible/Patient Record Form

IC 181890 under ICR 200906-0920-008 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form unnumbered Office-based Physicians eligible/Patient Record Form	Form
unnumbered Patient Record Form NAMCS 09-12 OMB ATT J.pdf	Form
NAMCS 09-12 Attachment H.pdf NAMCS Instruction booklet	IC Document

IC Title:

Office-based Physicians eligible/Patient Record Form

Agency IC Tracking Number:

Is this a Common Form?

IC Status: Modified

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	unnumbered	Patient Record Form	NAMCS 09-12 OMB ATT J.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 738

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	Previously Approved
Annual Number of Responses for this IC	22,140	-38,100	60,240
Annual IC Time Burden (Hours)	3,321	-1,699	5,020
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NAMCS Instruction booklet	NAMCS 09-12 Attachment H.pdf	05/11/2009

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