Home care for health care providers 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⚠️ Notice: This information collection may be referencing outdated material.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 #6 Home care for health care providers questionnaire Form and Instruction
Form #6 Home care for health care providers questionnaire Attachment 75 -- MPC Home Care for Health Care Providers Questionnaire.doc Form and Instruction
Attachment 79 -- MPC Home Health FAQs BROCHURE.doc Attachment 79 -- MPC Home Health FAQs BROCHURE IC Document
Attachment 77 -- MPC Home Health Contact Guide for Organizations.doc Attachment 77 -- MPC Home Health Contact Guide for Organizations IC Document
Attachment 78 -- MPC Home Health Cover Letter.doc Attachment 78 -- MPC Home Health Cover Letter IC Document
Attachment 80 -- MPC Home Health Fax Cover Sheet.doc Attachment 80 -- MPC Home Health Fax Cover Sheet IC Document
Attachment 81 -- MPC Home Health Fax or Mail Return Form.doc Attachment 81 -- MPC Home Health Fax or Mail Return Form IC Document
Attachment 82 -- MPC Home Health Instructions & Client Check List - FAX Version.doc Attachment 82 -- MPC Home Health Instructions & Client Check List - FAX Version IC Document
Attachment 83 -- MPC Home Health Instructions & Client Check List - Phone Version.doc Attachment 83 -- MPC Home Health Instructions & Client Check List - Phone Version IC Document

Information Collection (IC) Details

IC Title:	Home care for health care providers questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 #6	Home care for health care providers questionnaire	Attachment 75 -- MPC Home Care for Health Care Providers 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: 441	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	Previously Approved
Annual Number of Responses for this IC	2,867	2,867
Annual IC Time Burden (Hours)	239	239
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 79 -- MPC Home Health FAQs BROCHURE	Attachment 79 -- MPC Home Health FAQs BROCHURE.doc	08/24/2009
Attachment 77 -- MPC Home Health Contact Guide for Organizations	Attachment 77 -- MPC Home Health Contact Guide for Organizations.doc	08/24/2009
Attachment 78 -- MPC Home Health Cover Letter	Attachment 78 -- MPC Home Health Cover Letter.doc	08/24/2009
Attachment 80 -- MPC Home Health Fax Cover Sheet	Attachment 80 -- MPC Home Health Fax Cover Sheet.doc	08/24/2009
Attachment 81 -- MPC Home Health Fax or Mail Return Form	Attachment 81 -- MPC Home Health Fax or Mail Return Form.doc	08/24/2009
Attachment 82 -- MPC Home Health Instructions & Client Check List - FAX Version	Attachment 82 -- MPC Home Health Instructions & Client Check List - FAX Version.doc	08/24/2009
Attachment 83 -- MPC Home Health Instructions & Client Check List - Phone Version	Attachment 83 -- MPC Home Health Instructions & Client Check 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.