Separately billing doctors 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⚠️ Notice: This information collection may be referencing outdated material.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 #9 Separately billing doctors questionnaire Form and Instruction
Form #9 Separately billing doctors questionnaire Attachment 92 -- MPC SBD Questionnaire.doc Form and Instruction
Attachment 93 -- MPC SBD Contact Guide.doc Attachment 93 -- MPC SBD Contact Guide IC Document
Attachment 94 -- MPC SBD Cover Letter.doc Attachment 94 -- MPC SBD Cover Letter IC Document
Attachment 95 -- MPC SBD FAQs Brochure.doc Attachment 95 -- MPC SBD FAQs Brochure IC Document
Attachment 96 -- MPC SBD Fax Cover Sheet.doc Attachment 96 -- MPC SBD Fax Cover Sheet IC Document
Attachment 97 -- MPC SBD Fax or Mail Return Form.doc Attachment 97 -- MPC SBD Fax or Mail Return Form IC Document
Attachment 98 -- MPC SBD Instructions & Patient List - Phone Version.doc Attachment 98 -- MPC SBD Instructions & Patient List - Phone Version IC Document

Information Collection (IC) Details

IC Title:	Separately billing doctors 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 #9	Separately billing doctors questionnaire	Attachment 92 -- MPC SBD 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: 12,450	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	24,900	24,900
Annual IC Time Burden (Hours)	1,245	1,245
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 93 -- MPC SBD Contact Guide	Attachment 93 -- MPC SBD Contact Guide.doc	08/24/2009
Attachment 94 -- MPC SBD Cover Letter	Attachment 94 -- MPC SBD Cover Letter.doc	08/24/2009
Attachment 95 -- MPC SBD FAQs Brochure	Attachment 95 -- MPC SBD FAQs Brochure.doc	08/24/2009
Attachment 96 -- MPC SBD Fax Cover Sheet	Attachment 96 -- MPC SBD Fax Cover Sheet.doc	08/24/2009
Attachment 97 -- MPC SBD Fax or Mail Return Form	Attachment 97 -- MPC SBD Fax or Mail Return Form.doc	08/24/2009
Attachment 98 -- MPC SBD Instructions & Patient List - Phone Version	Attachment 98 -- MPC SBD Instructions & Patient List - Phone Version.doc	08/24/2009

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