MAPCP - Individuals Representing Community Health Teams and Networks

Evaluation of the Multi-Payer Advanced Primary Care Practice Demonstration

Documents and Forms

Document Name Document Type
Form CMS-10436 MAPCP - Individuals Representing Community Health Teams and Networks Form and Instruction
CMS-10436 Protocol - Community Health Teams Protocol_CHT_2-13-13.pdf Form and Instruction
CMS-10436 Protocol - Networks protocol_networks_2-13-13.pdf Form and Instruction
CMS-10436 Protocol - SASH Protocol_SASH_2-13-13.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	MAPCP - Individuals Representing Community Health Teams and Networks	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
Form and Instruction	CMS-10436	Protocol - Community Health Teams	Protocol_CHT_2-13-13.pdf	No	No	Paper Only
Form and Instruction	CMS-10436	Protocol - Networks	protocol_networks_2-13-13.pdf	No	No	Paper Only
Form and Instruction	CMS-10436	Protocol - SASH	Protocol_SASH_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: 24	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	18	18
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.