Information Collection

Medicare beneficiaries

IC 192996 under ICR 201009-0990-003 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-Medicare PHR Appx E questionnaire.doc	Other-questionnaire
0990-Medicare PHR Appx G intro phone script.doc	Other-phone script
0990-Medicare PHR Appx F draft postcard.doc	Other-post card
0990-Medicare PHR Appx D1 DRAFT patient letter.doc 0990-Medicare PHR Appx D1 DRAFT patient letter	IC Document
0990-PHRC-Appx C surveys consulted.doc 0990-PHRC-Appx C surveys consulted	IC Document
0990-Medicare PHRAppx D2 DRAFT patient FOLLOWUP Letter.doc 0990-Medicare PHRAppx D2 DRAFT patient FOLLOWUP Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-phone script	0990-Medicare PHR Appx G intro phone script.doc	No	No	Paper Only
Other-questionnaire	0990-Medicare PHR Appx E questionnaire.doc	No	No	Paper Only
Other-post card	0990-Medicare PHR Appx F draft postcard.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	208	208
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-Medicare PHR Appx D1 DRAFT patient letter	0990-Medicare PHR Appx D1 DRAFT patient letter.doc	09/23/2010
0990-PHRC-Appx C surveys consulted	0990-PHRC-Appx C surveys consulted.doc	09/23/2010
0990-Medicare PHRAppx D2 DRAFT patient FOLLOWUP Letter	0990-Medicare PHRAppx D2 DRAFT patient FOLLOWUP Letter.doc	09/23/2010

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