Information Collection

Quarterly Patient Information Form

IC 211233 under ICR 201403-0920-014 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 7a_Quarterly patient information form.docx	Other-WORD
Att 7b_Quarterly Patient Information Form Instructions 13XA.docx Quarterly Patient Information Form Instructions	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
Other-WORD			Att 7a_Quarterly patient information form.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Quarterly Patient Information Form Instructions	Att 7b_Quarterly Patient Information Form Instructions 13XA.docx	04/10/2014

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