Survey of Eligible Professionals and Administrators

Physician Quality Reporting System and the Electronic Prescribing Incentive Program

Documents and Forms

Document Name Document Type
Form CMS-10482 Survey of Eligible Professionals and Administrators Form and Instruction
CMS-10482 Attachment A - List of Eligible Professionals Attachment_A.pdf Form and Instruction
CMS-10482 Attachment B - Eligible Professionals and Practice Admin Attachment_B.pdf Form and Instruction
CMS-10482 Attachment B7 - Screen Shots Attachment B7_Screenshots_PQRS_Survey_Instr.pdf Form and Instruction
CMS-10482 Attachment C - Interview Topic Guides and Correspondence Attachment_C.pdf Form and Instruction
Attachment_B6_Fact_Sheet.pdf Attachment B6 - Fact Sheet IC Document
Attachment F_PQRS_Revisions_to_CMS.pdf Attachment F - Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Survey of Eligible Professionals and Administrators	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-10482	Attachment A - List of Eligible Professionals	Attachment_A.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10482	Attachment B - Eligible Professionals and Practice Administrators Surveys and Correspondence (B1-B5)	Attachment_B.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10482	Attachment B7 - Screen Shots	Attachment B7_Screenshots_PQRS_Survey_Instr.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10482	Attachment C - Interview Topic Guides and Correspondence	Attachment_C.pdf	No	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,450	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 60 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8,450	8,450
Annual IC Time Burden (Hours)	1,705	1,705
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment B6 - Fact Sheet	Attachment_B6_Fact_Sheet.pdf	11/26/2013
Attachment F - Crosswalk	Attachment F_PQRS_Revisions_to_CMS.pdf	11/26/2013

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