Medicaid Emergency Psychiatric Services Demonstration Evaluation - states

Medicaid Emergency Psychiatric Services Demonstration Evaluation

Documents and Forms

Document Name Document Type
Form CMS-10487 Medicaid Emergency Psychiatric Services Demonstration Evaluation - states Form and Instruction
CMS-10487 Key Informant Interview Protocols Attachment_B.pdf Form and Instruction
MEPD IRB Section 9 Rationale.pdf MEPD IRB Section 9 Rationale IC Document
MEPD Protocols Medical Record Review Consent.pdf MEPD Protocols Medical Record Review Consent IC Document
MEPD RequestFormExemption.pdf MEPD RequestFormExemption IC Document
NEIRB_exemption_granted_112213.pdf NEIRB_exemption_granted_112213 IC Document

Information Collection (IC) Details

IC Title:	Medicaid Emergency Psychiatric Services Demonstration Evaluation - states	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-10487	Key Informant Interview Protocols	Attachment_B.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	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	108	108
Annual IC Time Burden (Hours)	588	588
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MEPD IRB Section 9 Rationale	MEPD IRB Section 9 Rationale.pdf	02/27/2014
MEPD Protocols Medical Record Review Consent	MEPD Protocols Medical Record Review Consent.pdf	02/27/2014
MEPD RequestFormExemption	MEPD RequestFormExemption.pdf	02/27/2014
NEIRB_exemption_granted_112213	NEIRB_exemption_granted_112213.pdf	02/27/2014

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