Information Collection

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

IC 202895 under ICR 201206-0938-009 · OMB 0938-1183.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.