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

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

Documents and Forms

Document Name Document Type
Form CMS-10136 Medicare Demonstration Ambulatory Care Quality Measure Performance Assessment Tool (PAT) - PGP Demonstration Form and Instruction
CMS-10136 PGP_TD-PAT_Screen_ShotsJH PGP_TD-PAT_Screen_ShotsJH.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Demonstration Ambulatory Care Quality Measure Performance Assessment Tool (PAT) - PGP Demonstration	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	CMS-10136	PGP_TD-PAT_Screen_ShotsJH	PGP_TD-PAT_Screen_ShotsJH.pdf		Yes	Yes	Fillable Fileable

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: 10	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: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	790	790
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.