MAPCP - State Officials

Evaluation of the Multi-Payer Advanced Primary Care Practice Demonstration

Documents and Forms

Document Name Document Type
Form CMS-10436 MAPCP - State Officials Form and Instruction
CMS-10436 Protocol - State Officials Protocol_State_2-14-13.pdf Form and Instruction
CMS-10436 Protocol - DAAS care managers protocol_DAAS_care_mgrs_2-13-13.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	MAPCP - State Officials	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10436	Protocol - State Officials	Protocol_State_2-14-13.pdf		No	No	Paper Only
Form and Instruction	CMS-10436	Protocol - DAAS care managers	protocol_DAAS_care_mgrs_2-13-13.pdf		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	72	72
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.