Information Collection

MAPCP -- Practice/Health System Physicians and Administrators

IC 206738 under ICR 201304-0938-009 · OMB 0938-1211.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10436 MAPCP -- Practice/Health System Physicians and Administrators	Form and Instruction
CMS-10436 Protocol - Practice Protocol_Practice_2-13-13.pdf	Form and Instruction
CMS-10436 Protocol-Organized Delivery Protocol_organized_delivery_2-13-13.pdf	Form and Instruction
CMS-10436 Protocol - Provider Organization Protocol_provider_org_2-13-13.pdf	Form and Instruction

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
Form and Instruction	CMS-10436	Protocol - Practice	Protocol_Practice_2-13-13.pdf	No	No	Paper Only
Form and Instruction	CMS-10436	Protocol-Organized Delivery	Protocol_organized_delivery_2-13-13.pdf	No	No	Paper Only
Form and Instruction	CMS-10436	Protocol - Provider Organization	Protocol_provider_org_2-13-13.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 288

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	288	288
Annual IC Time Burden (Hours)	288	288
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.