Information Collection

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

IC 210263 under ICR 201402-0938-002 · OMB 0938-1256.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.