Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities

Medicaid Emergency Psychiatric Services Demonstration Evaluation

Documents and Forms

Document Name Document Type
Form CMS-10487 Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities Form and Instruction
CMS-10487 Key Informant Interview Protocols Attachment_B.pdf Form and Instruction
CMS-10487 Sampling Procedures for Medical Record Review Attachment_C.pdf Form and Instruction
CMS-10487 Medical Record Review Tools Attachment_D.pdf Form and Instruction
Crosswalks_508-cert_111813.pdf Crosswalk IC Document
Attachment_F.pdf Conceptual Framework IC Document
Attachment_G.pdf Technical Expert Panel IC Document
Attachment_H.pdf Confidentiality Pledge IC Document
Attachment_I.pdf Qualitative Data Coding Scheme IC Document

Information Collection (IC) Details

IC Title:	Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities	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-10487	Key Informant Interview Protocols	Attachment_B.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10487	Sampling Procedures for Medical Record Review	Attachment_C.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10487	Medical Record Review Tools	Attachment_D.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 81	Number of Respondents for Small Entity: 27

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	972	972
Annual IC Time Burden (Hours)	1,458	1,458
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalks_508-cert_111813.pdf	12/18/2013
Conceptual Framework	Attachment_F.pdf	12/23/2013
Technical Expert Panel	Attachment_G.pdf	12/23/2013
Confidentiality Pledge	Attachment_H.pdf	12/23/2013
Qualitative Data Coding Scheme	Attachment_I.pdf	12/23/2013

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