Information Collection

Evaluation of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration: Interview Protocols

IC 208578 under ICR 201309-0938-007 · OMB 0938-1223.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10483 Evaluation of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration: Interview Protocols	Form and Instruction
CMS-10483 Medical Home Survey PCMCH_Attachment_1_Survey_1_2013_V_3.0.pdf	Form and Instruction
CMS-10483 Medical Home Survey - Spanish version PCMCH_Attachment_Survey_Spanish_2_2013_V_1.0.pdf	Form and Instruction
PCMCH_OMB_Attach_Cover_Letter_First_Mailing_1_2013_V_3.0.pdf Cover Letter First Mailing	IC Document
PCMCH_OMB_Attach_Cover_Letter_First_Mailing_1_2013_V_3.0_SPA.pdf Cover Letter First Mailing - Spanish version	IC Document
PCMCH_OMB_Attach_Cover_Letter_Second_Mailing_1_2013_V_3.0.pdf Cover Letter Second Mailing	IC Document
PCMCH_OMB_Attach_Cover_Letter_Second_Mailing_1_2013_V_3 0_SPA.pdf Cover Letter Second Mailing - Spanish version	IC Document

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10483	Medical Home Survey	PCMCH_Attachment_1_Survey_1_2013_V_3.0.pdf		No	No	Fillable Fileable
Form and Instruction	CMS-10483	Medical Home Survey - Spanish version	PCMCH_Attachment_Survey_Spanish_2_2013_V_1.0.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,038

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	10,038	10,038
Annual IC Time Burden (Hours)	3,313	3,313
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter First Mailing	PCMCH_OMB_Attach_Cover_Letter_First_Mailing_1_2013_V_3.0.pdf	09/03/2013
Cover Letter First Mailing - Spanish version	PCMCH_OMB_Attach_Cover_Letter_First_Mailing_1_2013_V_3.0_SPA.pdf	09/03/2013
Cover Letter Second Mailing	PCMCH_OMB_Attach_Cover_Letter_Second_Mailing_1_2013_V_3.0.pdf	09/03/2013
Cover Letter Second Mailing - Spanish version	PCMCH_OMB_Attach_Cover_Letter_Second_Mailing_1_2013_V_3 0_SPA.pdf	09/03/2013

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