Information Collection

Separately billing doctors questionnaire

IC 191104 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⚠️ Notice: This information collection may be referencing outdated material.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 #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

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:

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 #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 %

table that charts list of burden
	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

table that charts IC Documents
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.