OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

IC 8171 under ICR 201202-0938-008 · OMB 0938-0568.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
attachment 05.zip Other-Facility Screening Interview S
attachment 06.zip Other-MCBS Facility Round 55 Instrum
CQuestionnaireLayout.pdf.pdf Other-CQuestionnaire Layout
AC Round 55.pdf Other-Spanish
CPS Round 55.pdf Other-Spanish
DU Round 55.pdf Other-Spanish
ER Round 55.pdf Other-Spanish
HH & HHS Round 55.pdf Other-Spanish
HIST & HIT Round 55.pdf Other-Spanish
IU Round 55.pdf Other-Spanish
NS Round 55.pdf Other-Spanish
PM & PMS Round 55.pdf Other-Spanish
AV Round 55.pdf Other-Spanish
DI Round 52.pdf Other-Spanish
EN & ENS Round 55.pdf Other-Spanish
HA Round 55.pdf Other-Spanish
HI & HIS Round 55.pdf Other-Spanish
IN & INS Round 55.pdf Other-Spanish
MC Round 55.pdf Other-Spanish
OM Round 55.pdf Other-Spanish
PS Round 55.pdf Other-Spanish
STRound55.pdf Other-Spanish
CL Round 55.pdf Other-Spanish
DM Round 55.pdf Other-Spanish
END Round 55.pdf Other-Spanish
HF Round 55.pdf Other-Spanish
HISMC & HIMC Round 55.pdf Other-Spanish
IP Round 55.pdf Other-Spanish
MP Round 55.pdf Other-Spanish
OP Round 55.pdf Other-Spanish
SCRound55.pdf Other-Spanish
USRound55.pdf Other-Spanish
DI2-Sp.pdf Other-Spanish Showcards
DM1-Sp.pdf Other-Spanish Showcards
glos-med abbrv dose-strength med-Spanish.pdf Other-Spanish Showcards
HA3-Sp.pdf Other-Spanish Showcards
HF3-Sp.pdf Other-Spanish Showcards
HF6-Sp.pdf Other-Spanish Showcards
HH2-Sp.pdf Other-Spanish Showcards
HH5-Sp.pdf Other-Spanish Showcards
HIMC1-Spanish.pdf Other-Spanish Showcards
IA1-Sp.pdf Other-Spanish Showcards
2010 Calendar-Spanish.pdf Other-Spanish Showcards
DI3-Sp.pdf Other-Spanish Showcards
DU-Sp.pdf Other-Spanish Showcards
HA1-Sp.pdf Other-Spanish Showcards
HF1-Sp.pdf Other-Spanish Showcards
HF7-Sp.pdf Other-Spanish Showcards
HH3-Sp.pdf Other-Spanish Showcards
HI3-Sp _not match_.pdf Other-Spanish Showcards
HIMC2A-Sp.pdf Other-Spanish Showcards
HIT1_front & back_-Sp.pdf Other-Spanish Showcards
IA2-Sp.pdf Other-Spanish Showcards
DI1A-Sp.pdf Other-Spanish Showcards
DI-Sp.pdf Other-Spanish Showcards
ENS-Sp.pdf Other-Spanish Showcards
HA2-Sp.pdf Other-Spanish Showcards
HF2-Sp.pdf Other-Spanish Showcards
HF5-Sp.pdf Other-Spanish Showcards
HH1-Sp.pdf Other-Spanish Showcards
HH4-Sp.pdf Other-Spanish Showcards
HI4-Sp.pdf Other-Spanish Showcards
HIMC2-SP.pdf Other-Spanish Showcards
HIT2-Sp.pdf Other-Spanish Showcards
IA3-Sp.pdf Other-Spanish Showcards
IA3-Sp.pdf Other-Spanish Showcards
KN1-Sp.pdf Other-Spanish Showcards
KN6-Sp.pdf Other-Spanish Showcards
KN13-Sp.pdf Other-Spanish Showcards
MP2-Sp.pdf Other-Spanish Showcards
MP5-Sp.pdf Other-Spanish Showcards
OM3-Sp.pdf Other-Spanish Showcards
PA1_PA2_PA4-Sp.pdf Other-Spanish Showcards
PM1-Sp.pdf Other-Spanish Showcards
RX1-Sp.pdf Other-Spanish Showcards
SC1-Sp.pdf Other-Spanish Showcards
SC4-Sp.pdf Other-Spanish Showcards
ST2-Sp.pdf Other-Spanish Showcards
US2-Sp.pdf Other-Spanish Showcards
IU-Sp.pdf Other-Spanish Showcards
KN4-Sp.pdf Other-Spanish Showcards
KN9-Sp.pdf Other-Spanish Showcards
MP1-Sp.pdf Other-Spanish Showcards
MP4-Sp.pdf Other-Spanish Showcards
OM2-Sp.pdf Other-Spanish Showcards
OM5-Sp.pdf Other-Spanish Showcards
PD2-Sp.pdf Other-Spanish Showcards
ref card for med specialty-SP.pdf Other-Spanish Showcards
SC1A-Sp.pdf Other-Spanish Showcards
SC3-Sp.pdf Other-Spanish Showcards
ST1-Sp.pdf Other-Spanish Showcards
US1-Sp.pdf Other-Spanish Showcards
IA4-Sp.pdf Other-Spanish Showcards
KN2-Sp.pdf Other-Spanish Showcards
KN7-Sp.pdf Other-Spanish Showcards
KN14-Sp.pdf Other-Spanish Showcards
MP3-Sp.pdf Other-Spanish Showcards
OM1-Sp.pdf Other-Spanish Showcards
OM4-Sp.pdf Other-Spanish Showcards
PD1-Sp.pdf Other-Spanish Showcards
pronunc guide-Sp.pdf Other-Spanish Showcards
RX2-Sp.pdf Other-Spanish Showcards
SC2-Sp.pdf Other-Spanish Showcards
statement terms glos-Spanish.pdf Other-Spanish Showcards
2010 Calendar-Eng.pdf Other-English Showcards
DI3-Eng.pdf Other-English Showcards
DU-Eng.pdf Other-English Showcards
Exit Screens_Showcard.pdf Other-English Showcards
HA2-Eng.pdf Other-English Showcards
HF2-Eng.pdf Other-English Showcards
HF5-Eng.pdf Other-English Showcards
HH1-Eng.pdf Other-English Showcards
HH4-Eng.pdf Other-English Showcards
HI3 E-K.pdf Other-English Showcards
HI3 O-S.pdf Other-English Showcards
HIMC1-Eng.pdf Other-English Showcards
HIMC-Eng.pdf Other-English Showcards
IA1a-Eng.pdf Other-English Showcards
IA Glossary.pdf Other-English Showcards
IA2-Eng.pdf Other-English Showcards
KN1-Eng.pdf Other-English Showcards
KN6-Eng.pdf Other-English Showcards
KN13-Eng.pdf Other-English Showcards
MP1-Eng.pdf Other-English Showcards
MP4-Eng.pdf Other-English Showcards
OM2-Eng.pdf Other-English Showcards
OM5-Eng.pdf Other-Spanish Showcards
PD2-Eng.pdf Other-English Showcards
R56 Continuing Showcard List.pdf Other-English Showcards
RX2-Eng.pdf Other-English Showcards
SC2-Eng.pdf Other-English Showcards
spec keys for CAPI.pdf Other-English Showcards
state abbrv.pdf Other-English Showcards
US2-Eng.pdf Other-English Showcards
DI1A-Eng.pdf Other-English Showcards
DI-Eng.pdf Other-English Showcards
ENS-Eng.pdf Other-English Showcards
gloss of pres med abbrv.pdf Other-English Showcards
HA3-Eng.pdf Other-English Showcards
HF3-Eng.pdf Other-English Showcards
HF6-Eng.pdf Other-English Showcards
HH2-Eng.pdf Other-English Showcards
HH5-Eng.pdf Other-English Showcards
HI3 L-M.pdf Other-English Showcards
HI3 T-W.pdf Other-English Showcards
HIMC2A-Eng.pdf Other-English Showcards
HIT1_front & back_-Eng.pdf Other-English Showcards
IA1a-Sp.pdf Other-English Showcards
IA3-Eng.pdf Other-English Showcards
Interrupt Menu Showcard .pdf Other-English Showcards
KN2-Eng.pdf Other-English Showcards
KN7-Eng.pdf Other-English Showcards
KN14-Eng.pdf Other-English Showcards
MP2-Eng.pdf Other-English Showcards
MP5-Eng.pdf Other-English Showcards
OM3-Eng.pdf Other-English Showcards
PA1_PA2_PA4.pdf Other-English Showcards
PM1-Eng.pdf Other-English Showcards
Ref card for med provider.pdf Other-English Showcards
SC1A-Eng.pdf Other-English Showcards
SC3-Eng.pdf Other-English Showcards
ST1-Eng.pdf Other-English Showcards
statement terms glos.pdf Other-English Showcards
DI2-Eng.pdf Other-English Showcards
DM1-Eng.pdf Other-English Showcards
Examples of types of med drs.pdf Other-English Showcards
HA1-Eng.pdf Other-English Showcards
HF1-Eng.pdf Other-English Showcards
HF4-Eng.pdf Other-English Showcards
HF7-Eng.pdf Other-English Showcards
HH3-Eng.pdf Other-English Showcards
HI3 A-D.pdf Other-English Showcards
HI3 N.pdf Other-English Showcards
HI4-Eng.pdf Other-English Showcards
HIMC2-Eng.pdf Other-English Showcards
HIT2-Eng.pdf Other-English Showcards
IA1-Eng.pdf Other-English Showcards
IA4-Eng.pdf Other-English Showcards
IU-Eng.pdf Other-English Showcards
KN4-Eng.pdf Other-English Showcards
Language Identification Card.pdf Other-English Showcards
KN9-Eng.pdf Other-English Showcards
MP3-Eng.pdf Other-English Showcards
OM1-Eng.pdf Other-English Showcards
OM4-Eng.pdf Other-English Showcards
PD1-Eng.pdf Other-English Showcards
pronunc guide.pdf Other-English Showcards
RX1-Eng.pdf Other-English Showcards
SC1-Eng.pdf Other-English Showcards
SC4-Eng.pdf Other-English Showcards
ST2-Eng.pdf Other-English Showcards
US1-Eng.pdf Other-English Showcards
AC_04.01.0001.pdf Other-Section By Section
CE_04.01.0000.pdf Other-Section By Section
DI_04.01.0002.pdf Other-Section By Section
END_04.01.0000.pdf Other-Section By Section
EX_03.01.0000.pdf Other-Section By Section
HH_05.01.0000.pdf Other-Section By Section
HIS_05.01.0000.pdf Other-Section By Section
IP_05.01.0000.pdf Other-Section By Section
KN_02.01.0003.pdf Other-Section By Section
OM_05.01.0000.pdf Other-Section By Section
PM_06.01.0001.pdf Other-Section By Section
RX_05.01.0000.pdf Other-Section By Section
US_05.01.0001.pdf Other-Section By Section
AV_05.01.0000.pdf Other-Section By Section
CL_07.01.0000.pdf Other-Section By Section
DM_05.01.0000.pdf Other-Section By Section
ENS_07.01.0001.pdf Other-Section By Section
HA_05.01.0003.pdf Other-Section By Section
HHS_04.01.0000.pdf Other-Section By Section
IA_05.01.0000.pdf Other-Section By Section
IRQ_05.01.0000.pdf Other-Section By Section
MP_05.01.0000.pdf Other-Section By Section
OP_05.01.0000.pdf Other-Section By Section
PMS_05.01.0000.pdf Other-Section By Section
SC_05.01.0003.pdf Other-Section By Section
BackgroundVariables_07.01.0000.pdf Other-Section By Section
CPS_07.01.0000.pdf Other-Section By Section
DU_04.01.0000.pdf Other-Section By Section
ER_04.01.0000.pdf Other-Section By Section
HF_05.01.0008.pdf Other-Section By Section
HI_05.01.0001.pdf Other-Section By Section
IN_05.01.0001.pdf Other-Section By Section
IU_05.01.0000.pdf Other-Section By Section
NS_07.01.0003.pdf Other-Section By Section
PA_04.01.0001.pdf Other-Section By Section
PS_04.01.0000.pdf Other-Section By Section
ST_05.01.0001.pdf Other-Section By Section
ConditionRoster0301_0000PopUpVars.pdf Other-Roster
EventRosterBeginDateRV0301_0000PopUpVars.pdf Other-Roster
PMRoster04010000PopUpVars.pdf Other-Roster
StatementChargeBundleRoster0501_0000PopUpVars.pdf Other-Roster
StatementOMEditRoster0301_0000PopUpVars.pdf Other-Roster
DMRoster0401_0000PopUpVars.pdf Other-Roster
PersonRoster0301_0000PopUpVars.pdf Other-Roster
ProviderRoster0301_0000PopUpVars.pdf Other-Roster
StatementEventEditRoster0301_0000PopUpVars.pdf Other-Roster
EventRosterBeginDate0301_0000PopUpVars.pdf Other-Roster
PlanRoster0301_0000PopUpVars.pdf Other-Roster
SOPRoster0301_0000PopUpVars.pdf Other-Roster
StatementEventRoster0301_0000PopUpVars.pdf Other-Roster
ATTACHMENTHI1.pdf Other-General Specifications
GeneralSpecifications07010001.pdf Other-General Specifications
GeneralSpecificationsDates07010001.pdf Other-General Specifications
GeneralSpecificationsQuestionnaireFlow07010001.pdf Other-General Specifications
MCBSWVSTechnicalNotes0501_0000.pdf Other-General Specifications
ATTACHMENTHI2.pdf Other-General Specifications
GeneralSpecificationsAttachments07010001.pdf Other-General Specifications
GeneralSpecificationsDefaultSpecification07010001.pdf Other-General Specifications
GeneralSpecificationsScreenTypes07010001.pdf Other-General Specifications
GeneralSpecificationsDatabase07010001.pdf Other-General Specifications
GeneralSpecificationsGlobalDisplays07010001.pdf Other-General Specifications
GeneralSpecificationsSectionOverview07010001.pdf Other-General Specifications
entire questionnaire condensed.pdf Other-Entire Questionnaire Condensed
attachment 01.zip
attachment 01		IC Document
attachment 02.zip
attachment 02		IC Document
attachment 07.zip
attachment 07		IC Document
attachment 08.zip
attachment 08		IC Document
attachment 10.zip
attachment 10		IC Document
Attachment 3 - UPDMCBSBrochure.pdf
Attachment 3 - UPDMCBSBrochure		IC Document
Attachment 3 - UPDAttheDoorBrochure2010.pdf
Attachment 3 - UPDMCBSBrochure		IC Document
2010AdvanceLetterwithletterhead.pdf
2010AdvanceLetterwithletterhead		IC Document
MCBSConfidentialityAgreement.pdf
MCBSConfidentialityAgreement		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Other-English Showcards KN13-Eng.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsDefaultSpecification07010001.pdf Yes Yes Printable Only
Other-Facility Screening Interview Script for Meeting with Facility Administrators attachment 05.zip Yes Yes Printable Only
Other-MCBS Facility Round 55 Instrument attachment 06.zip Yes Yes Printable Only
Other-English Showcards DI2-Eng.pdf Yes Yes Printable Only
Other-English Showcards DM1-Eng.pdf Yes Yes Printable Only
Other-English Showcards Examples of types of med drs.pdf Yes Yes Printable Only
Other-English Showcards HA1-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF1-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF4-Eng.pdf Yes Yes Printable Only
Other-English Showcards HIT2-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA2-Eng.pdf Yes Yes Printable Only
Other-English Showcards OM2-Eng.pdf Yes Yes Printable Only
Other-English Showcards spec keys for CAPI.pdf Yes Yes Printable Only
Other-English Showcards state abbrv.pdf Yes Yes Printable Only
Other-English Showcards US2-Eng.pdf Yes Yes Printable Only
Other-English Showcards DI1A-Eng.pdf Yes Yes Printable Only
Other-English Showcards DI-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP2-Eng.pdf Yes Yes Printable Only
Other-English Showcards PA1_PA2_PA4.pdf Yes Yes Printable Only
Other-Entire Questionnaire Condensed entire questionnaire condensed.pdf Yes Yes Printable Only
Other-Spanish Showcards OM2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM5-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards PD2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards ref card for med specialty-SP.pdf Yes Yes Printable Only
Other-English Showcards HIMC2A-Eng.pdf Yes Yes Printable Only
Other-Section By Section CE_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section OM_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section DM_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section ENS_07.01.0001.pdf Yes Yes Printable Only
Other-Section By Section HA_05.01.0003.pdf Yes Yes Printable Only
Other-Spanish ER Round 55.pdf Yes Yes Printable Only
Other-Spanish HH & HHS Round 55.pdf Yes Yes Printable Only
Other-Spanish HIST & HIT Round 55.pdf Yes Yes Printable Only
Other-Spanish IU Round 55.pdf Yes Yes Printable Only
Other-Spanish NS Round 55.pdf Yes Yes Printable Only
Other-Spanish Showcards PA1_PA2_PA4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards PM1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards RX1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC1-Sp.pdf Yes Yes Printable Only
Other-Spanish AV Round 55.pdf Yes Yes Printable Only
Other-Spanish HA Round 55.pdf Yes Yes Printable Only
Other-Spanish HI & HIS Round 55.pdf Yes Yes Printable Only
Other-Spanish AC Round 55.pdf Yes Yes Printable Only
Other-Spanish CPS Round 55.pdf Yes Yes Printable Only
Other-General Specifications ATTACHMENTHI2.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsGlobalDisplays07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsSectionOverview07010001.pdf Yes Yes Printable Only
Other-English Showcards HF2-Eng.pdf Yes Yes Printable Only
Other-English Showcards ENS-Eng.pdf Yes Yes Printable Only
Other-English Showcards US1-Eng.pdf Yes Yes Printable Only
Other-Section By Section IP_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section KN_02.01.0003.pdf Yes Yes Printable Only
Other-Spanish IP Round 55.pdf Yes Yes Printable Only
Other-Spanish MP Round 55.pdf Yes Yes Printable Only
Other-Spanish EN & ENS Round 55.pdf Yes Yes Printable Only
Other-Spanish Showcards HA2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF5-Sp.pdf Yes Yes Printable Only
Other-Spanish PM & PMS Round 55.pdf Yes Yes Printable Only
Other-Spanish OP Round 55.pdf Yes Yes Printable Only
Other-Spanish Showcards DI2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF7-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HI3-Sp _not match_.pdf Yes Yes Printable Only
Other-Spanish Showcards ENS-Sp.pdf Yes Yes Printable Only
Other-English Showcards ST2-Eng.pdf Yes Yes Printable Only
Other-Spanish DI Round 52.pdf Yes Yes Printable Only
Other-Spanish Showcards HA1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HIMC2A-Sp.pdf Yes Yes Printable Only
Other-Section By Section AC_04.01.0001.pdf Yes Yes Printable Only
Other-Section By Section END_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section HH_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section US_05.01.0001.pdf Yes Yes Printable Only
Other-Section By Section AV_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section CL_07.01.0000.pdf Yes Yes Printable Only
Other-Section By Section CPS_07.01.0000.pdf Yes Yes Printable Only
Other-Spanish IN & INS Round 55.pdf Yes Yes Printable Only
Other-Spanish MC Round 55.pdf Yes Yes Printable Only
Other-Spanish OM Round 55.pdf Yes Yes Printable Only
Other-Spanish PS Round 55.pdf Yes Yes Printable Only
Other-Spanish HISMC & HIMC Round 55.pdf Yes Yes Printable Only
Other-Section By Section DI_04.01.0002.pdf Yes Yes Printable Only
Other-English Showcards HIMC2-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA Glossary.pdf Yes Yes Printable Only
Other-English Showcards KN6-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP1-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP4-Eng.pdf Yes Yes Printable Only
Other-English Showcards R56 Continuing Showcard List.pdf Yes Yes Printable Only
Other-English Showcards gloss of pres med abbrv.pdf Yes Yes Printable Only
Other-English Showcards HF3-Eng.pdf Yes Yes Printable Only
Other-Section By Section BackgroundVariables_07.01.0000.pdf Yes Yes Printable Only
Other-Section By Section DU_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section HF_05.01.0008.pdf Yes Yes Printable Only
Other-Section By Section IN_05.01.0001.pdf Yes Yes Printable Only
Other-Section By Section IU_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section NS_07.01.0003.pdf Yes Yes Printable Only
Other-General Specifications ATTACHMENTHI1.pdf Yes Yes Printable Only
Other-CQuestionnaire Layout CQuestionnaireLayout.pdf.pdf Yes Yes Printable Only
Other-Spanish Showcards HI4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HIMC2-SP.pdf Yes Yes Printable Only
Other-Spanish Showcards IA3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC4-Sp.pdf Yes Yes Printable Only
Other-Spanish SCRound55.pdf Yes Yes Printable Only
Other-Roster StatementChargeBundleRoster0501_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster StatementOMEditRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster DMRoster0401_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster PersonRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Section By Section ER_04.01.0000.pdf Yes Yes Printable Only
Other-Roster PMRoster04010000PopUpVars.pdf Yes Yes Printable Only
Other-Spanish Showcards MP4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards ST1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN6-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN13-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards glos-med abbrv dose-strength med-Spanish.pdf Yes Yes Printable Only
Other-Section By Section HIS_05.01.0000.pdf Yes Yes Printable Only
Other-Spanish DU Round 55.pdf Yes Yes Printable Only
Other-Spanish Showcards HF6-Sp.pdf Yes Yes Printable Only
Other-Section By Section PM_06.01.0001.pdf Yes Yes Printable Only
Other-Section By Section HHS_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section IA_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section OP_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section PMS_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section SC_05.01.0003.pdf Yes Yes Printable Only
Other-English Showcards HA2-Eng.pdf Yes Yes Printable Only
Other-English Showcards HI3 E-K.pdf Yes Yes Printable Only
Other-Spanish USRound55.pdf Yes Yes Printable Only
Other-Spanish Showcards HH3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HIT1_front & back_-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards IA2-Sp.pdf Yes Yes Printable Only
Other-English Showcards IA4-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN4-Eng.pdf Yes Yes Printable Only
Other-Spanish Showcards IA3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM3-Sp.pdf Yes Yes Printable Only
Other-English Showcards HIT1_front & back_-Eng.pdf Yes Yes Printable Only
Other-Spanish Showcards SC3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards pronunc guide-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards RX2-Sp.pdf Yes Yes Printable Only
Other-English Showcards PD2-Eng.pdf Yes Yes Printable Only
Other-English Showcards DU-Eng.pdf Yes Yes Printable Only
Other-English Showcards Exit Screens_Showcard.pdf Yes Yes Printable Only
Other-Spanish Showcards IA4-Sp.pdf Yes Yes Printable Only
Other-English Showcards HH2-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH5-Eng.pdf Yes Yes Printable Only
Other-Roster PlanRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Showcards IA3-Eng.pdf Yes Yes Printable Only
Other-English Showcards Interrupt Menu Showcard .pdf Yes Yes Printable Only
Other-English Showcards MP5-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP3-Eng.pdf Yes Yes Printable Only
Other-English Showcards pronunc guide.pdf Yes Yes Printable Only
Other-Section By Section HI_05.01.0001.pdf Yes Yes Printable Only
Other-Roster ProviderRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster StatementEventEditRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster EventRosterBeginDate0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Showcards HF5-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH1-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH4-Eng.pdf Yes Yes Printable Only
Other-English Showcards HI3 O-S.pdf Yes Yes Printable Only
Other-English Showcards HIMC1-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA1a-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN1-Eng.pdf Yes Yes Printable Only
Other-Spanish Showcards OM5-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH3-Eng.pdf Yes Yes Printable Only
Other-English Showcards HI3 A-D.pdf Yes Yes Printable Only
Other-English Showcards HI3 N.pdf Yes Yes Printable Only
Other-English Showcards HI4-Eng.pdf Yes Yes Printable Only
Other-English Showcards Language Identification Card.pdf Yes Yes Printable Only
Other-Section By Section MP_05.01.0000.pdf Yes Yes Printable Only
Other-Roster StatementEventRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsAttachments07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsScreenTypes07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsDatabase07010001.pdf Yes Yes Printable Only
Other-Section By Section IRQ_05.01.0000.pdf Yes Yes Printable Only
Other-Spanish Showcards 2010 Calendar-Spanish.pdf Yes Yes Printable Only
Other-Spanish Showcards DI3-Sp.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsQuestionnaireFlow07010001.pdf Yes Yes Printable Only
Other-General Specifications MCBSWVSTechnicalNotes0501_0000.pdf Yes Yes Printable Only
Other-English Showcards SC1A-Eng.pdf Yes Yes Printable Only
Other-Spanish Showcards HIT2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP5-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH5-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HIMC1-Spanish.pdf Yes Yes Printable Only
Other-Spanish Showcards IA1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards DU-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards DI1A-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards DI-Sp.pdf Yes Yes Printable Only
Other-English Showcards OM4-Eng.pdf Yes Yes Printable Only
Other-English Showcards HIMC-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN7-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN14-Eng.pdf Yes Yes Printable Only
Other-English Showcards PM1-Eng.pdf Yes Yes Printable Only
Other-English Showcards Ref card for med provider.pdf Yes Yes Printable Only
Other-Roster SOPRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecifications07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsDates07010001.pdf Yes Yes Printable Only
Other-English Showcards HI3 L-M.pdf Yes Yes Printable Only
Other-English Showcards ST1-Eng.pdf Yes Yes Printable Only
Other-English Showcards statement terms glos.pdf Yes Yes Printable Only
Other-English Showcards OM1-Eng.pdf Yes Yes Printable Only
Other-English Showcards RX1-Eng.pdf Yes Yes Printable Only
Other-Section By Section EX_03.01.0000.pdf Yes Yes Printable Only
Other-English Showcards KN2-Eng.pdf Yes Yes Printable Only
Other-Spanish Showcards US1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM4-Sp.pdf Yes Yes Printable Only
Other-English Showcards IU-Eng.pdf Yes Yes Printable Only
Other-English Showcards SC4-Eng.pdf Yes Yes Printable Only
Other-Section By Section RX_05.01.0000.pdf Yes Yes Printable Only
Other-English Showcards SC1-Eng.pdf Yes Yes Printable Only
Other-Spanish STRound55.pdf Yes Yes Printable Only
Other-Spanish CL Round 55.pdf Yes Yes Printable Only
Other-Spanish DM Round 55.pdf Yes Yes Printable Only
Other-Spanish END Round 55.pdf Yes Yes Printable Only
Other-Spanish HF Round 55.pdf Yes Yes Printable Only
Other-Spanish Showcards HH1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards ST2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards US2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards IU-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC1A-Sp.pdf Yes Yes Printable Only
Other-English Showcards 2010 Calendar-Eng.pdf Yes Yes Printable Only
Other-English Showcards DI3-Eng.pdf Yes Yes Printable Only
Other-English Showcards RX2-Eng.pdf Yes Yes Printable Only
Other-English Showcards SC2-Eng.pdf Yes Yes Printable Only
Other-English Showcards HA3-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF6-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF7-Eng.pdf Yes Yes Printable Only
Other-Spanish Showcards DM1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HA3-Sp.pdf Yes Yes Printable Only
Other-Section By Section PS_04.01.0000.pdf Yes Yes Printable Only
Other-Roster ConditionRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster EventRosterBeginDateRV0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Spanish Showcards KN9-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN7-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN14-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards PD1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards statement terms glos-Spanish.pdf Yes Yes Printable Only
Other-Section By Section PA_04.01.0001.pdf Yes Yes Printable Only
Other-Section By Section ST_05.01.0001.pdf Yes Yes Printable Only
Other-English Showcards HI3 T-W.pdf Yes Yes Printable Only
Other-English Showcards IA1a-Sp.pdf Yes Yes Printable Only
Other-English Showcards OM3-Eng.pdf Yes Yes Printable Only
Other-English Showcards SC3-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN9-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA1-Eng.pdf Yes Yes Printable Only
Other-English Showcards PD1-Eng.pdf Yes Yes Printable Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 48,651 0 1 0 0 48,650
Annual IC Time Burden (Hours) 58,450 0 1,388 0 0 57,062
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
attachment 01 attachment 01.zip 08/25/2010
attachment 02 attachment 02.zip 08/25/2010
attachment 07 attachment 07.zip 08/25/2010
attachment 08 attachment 08.zip 08/25/2010
attachment 10 attachment 10.zip 08/25/2010
Attachment 3 - UPDMCBSBrochure Attachment 3 - UPDMCBSBrochure.pdf 12/17/2010
Attachment 3 - UPDMCBSBrochure Attachment 3 - UPDAttheDoorBrochure2010.pdf 12/17/2010
2010AdvanceLetterwithletterhead 2010AdvanceLetterwithletterhead.pdf 02/06/2012
MCBSConfidentialityAgreement MCBSConfidentialityAgreement.pdf 02/06/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.