Office-based Physicians eligible/Patient Record Form

NCHS National Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.