Information Collection

Reimbursement Template -Physician Services Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415

IC 205036 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Combined Primary Care Bump and VFC SPA Template-tc--clean.docx Other-null

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Reimbursement Template -Physician Services Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415	Agency IC Tracking Number:	18116

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 447.410

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-null			Combined Primary Care Bump and VFC SPA Template-tc--clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.