(Physician) Survey of Access to Home Health Services for Medicare Beneficiaries

Surveys of Physicians and Home Health Agencies to Assess Access Issues for Specific Medicare Beneficiaries as Defined in Section 3131(d) of the ACA

Documents and Forms

Document Name Document Type
HHSC_Physician postcard text 03292012_508.pdf Other-Post Card
HHSC_Prompting script 03292012_508.pdf Instruction
HHSC_Physician prenotice letter REVISED 11-19-2012.pdf Other-Cover Letter
Physician cover letter REVISED 11-19-12.pdf Other-Cover Letter
CMS-10429 (Physician) Survey of Access to Home Health Services for HHSC_Physician Survey [rev 6-27-2012].pdf Form

Information Collection (IC) Details

IC Title:	(Physician) Survey of Access to Home Health Services for Medicare Beneficiaries	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Post Card			HHSC_Physician postcard text 03292012_508.pdf	No	No	Printable Only
Instruction			HHSC_Prompting script 03292012_508.pdf	No	No	Fillable Printable
Form	CMS-10429	(Physician) Survey of Access to Home Health Services for Medicare Beneficiaries	HHSC_Physician Survey [rev 6-27-2012].pdf	No	No	Fillable Printable
Other-Cover Letter			HHSC_Physician prenotice letter REVISED 11-19-2012.pdf	No		Paper Only
Other-Cover Letter			Physician cover letter REVISED 11-19-12.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 275	Number of Respondents for Small Entity: 215

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	275	275
Annual IC Time Burden (Hours)	69	69
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.