Permission Forms for the MEPS-MPC

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⚠️ Notice: This information collection may be referencing outdated material.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 #4 Permission Forms for the MEPS-MPC Form and Instruction
Form #4 Pharmacy Form Attachment 73 -- HC Permission Form for the MEPS-MPC -- Pharmacy.doc Form and Instruction
Form #5 Provider Form Attachment 74 -- HC Permission Form for the MEPS-MPC -- Provider.doc Form and Instruction
Attachment 22 -- HC MEPS-MPC Permission Form FAQs.doc Attachment 22 -- HC MEPS-MPC Permission Form FAQs IC Document

Information Collection (IC) Details

IC Title:	Permission Forms for the MEPS-MPC	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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 #4	Pharmacy Form	Attachment 73 -- HC Permission Form for the MEPS-MPC -- Pharmacy.doc		Yes	Yes	Paper Only
Form and Instruction	Form #5	Provider Form	Attachment 74 -- HC Permission Form for the MEPS-MPC -- Provider.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-78,000	78,000
Annual IC Time Burden (Hours)	-3,900	3,900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 22 -- HC MEPS-MPC Permission Form FAQs	Attachment 22 -- HC MEPS-MPC Permission Form FAQs.doc	08/21/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.