Information Collection

Permission Forms for the MEPS-MPC

IC 191100 under ICR 200910-0935-001 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #4 Permission Forms for the MEPS-MPC	Form and Instruction
Form #4 Pharmacy Form Attachment 73 -- HC Permission Form for the MEPS-MPC -- Pharmacy.doc	Form and Instruction
Form #5 Provider Form Attachment 74 -- HC Permission Form for the MEPS-MPC -- Provider.doc	Form and Instruction
Attachment 22 -- HC MEPS-MPC Permission Form FAQs.doc Attachment 22 -- HC MEPS-MPC Permission Form FAQs	IC Document

IC Title:

Permission Forms for the MEPS-MPC

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	Form #4	Pharmacy Form	Attachment 73 -- HC Permission Form for the MEPS-MPC -- Pharmacy.doc		Yes	Yes	Paper Only
Form and Instruction	Form #5	Provider Form	Attachment 74 -- HC Permission Form for the MEPS-MPC -- Provider.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	78,000	78,000
Annual IC Time Burden (Hours)	3,900	3,900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 22 -- HC MEPS-MPC Permission Form FAQs	Attachment 22 -- HC MEPS-MPC Permission Form FAQs.doc	08/21/2009

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