Office based providers questionnaire

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form Form #8 Office based providers questionnaire Form and Instruction
Form #8 Office based providers questionnaire Attachment 84 -- MPC Office Based Providers Questionnaire.doc Form and Instruction
Attachment 85 -- MPC Office Based Cover Letter.doc Attachment 85 -- MPC Office Based Cover Letter IC Document
Attachment 86 -- MPC Office Based FAQs Brochure.doc Attachment 86 -- MPC Office Based FAQs Brochure IC Document
Attachment 87 -- MPC Office Based Fax Cover Sheet.doc Attachment 87 -- MPC Office Based Fax Cover Sheet IC Document
Attachment 88 -- MPC Office Based Fax or Mail Return Form.doc Attachment 88 -- MPC Office Based Fax or Mail Return Form IC Document
Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version.doc Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version IC Document
Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version.doc Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version IC Document
Attachment 91 -- MPC Office Based Contact Guide.doc Attachment 91 -- MPC Office Based Contact Guide IC Document

Information Collection (IC) Details

IC Title:	Office based providers questionnaire	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	Form #8	Office based providers questionnaire	Attachment 84 -- MPC Office Based Providers Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13,665	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
Annual Number of Responses for this IC	79,257	79,257
Annual IC Time Burden (Hours)	6,605	6,605
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 85 -- MPC Office Based Cover Letter	Attachment 85 -- MPC Office Based Cover Letter.doc	08/24/2009
Attachment 86 -- MPC Office Based FAQs Brochure	Attachment 86 -- MPC Office Based FAQs Brochure.doc	08/24/2009
Attachment 87 -- MPC Office Based Fax Cover Sheet	Attachment 87 -- MPC Office Based Fax Cover Sheet.doc	08/24/2009
Attachment 88 -- MPC Office Based Fax or Mail Return Form	Attachment 88 -- MPC Office Based Fax or Mail Return Form.doc	08/24/2009
Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version	Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version.doc	08/24/2009
Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version	Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version.doc	08/24/2009
Attachment 91 -- MPC Office Based Contact Guide	Attachment 91 -- MPC Office Based Contact Guide.doc	08/24/2009

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