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

Evaluation of the Multi-Payer Advance Primary Care Practice (MAPCP) Demonstration: Conduct Beneficiary Experience with Care Surveys

Documents and Forms

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

Information Collection (IC) Details

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

	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

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.