Evaluation of the Multi-payer Advanced Primary Care Practice Demonstration:

Evaluation of the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration: Provider Survey

Documents and Forms

Document Name Document Type
Form CMS-10485 Evaluation of the Multi-payer Advanced Primary Care Practice Demonstration: Form and Instruction
CMS-10485 MAPCP Practice Manager Survey Att D2 - MAPCP Practice Manager Survey_102714 clean.docx Form and Instruction
CMS-10485 MAPCP Provider Survey Att D1 - MAPCP Provider Survey_102714 clean.docx Form and Instruction
AttE-RevisionsMAPCP-ProvSurv.pdf Crosswalk IC Document
Attachment C - 102714 clean.doc Recruitment Communication IC Document

Information Collection (IC) Details

IC Title:	Evaluation of the Multi-payer Advanced Primary Care Practice Demonstration:	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-10485	MAPCP Provider Survey	Att D1 - MAPCP Provider Survey_102714 clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10485	MAPCP Practice Manager Survey	Att D2 - MAPCP Practice Manager Survey_102714 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,799	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: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,602	6,602
Annual IC Time Burden (Hours)	1,160	1,160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	AttE-RevisionsMAPCP-ProvSurv.pdf	02/03/2014
Recruitment Communication	Attachment C - 102714 clean.doc	11/13/2014

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