Information Collection

Medicare Demonstration Ambulatory Care Quality Measure Performance Assessment Tool (PAT) -EHR Demonstration

IC 186735 under ICR 201106-0938-013 · OMB 0938-0941.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0941 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10136 Medicare Demonstration Ambulatory Care Quality Measure Performance Assessment Tool (PAT) -EHR Demonstration	Form and Instruction
CMS-10136 MCMP PAT MCMP PAT Screenshots 052508(B).ppt	Form and Instruction

IC Title:

Medicare Demonstration Ambulatory Care Quality Measure Performance Assessment Tool (PAT) -EHR Demonstration

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10136	MCMP PAT	MCMP PAT Screenshots 052508(B).ppt		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Demonstration, Evaluation and Research Studies (DERS)

FR Citation: 72 FR 17918

Number of Respondents: 400

Number of Respondents for Small Entity: 400

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	9,600	9,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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