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Federal forms, ICRs, and supporting documents

Information Collection

Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)

IC 222041 under ICR 201410-0938-016 · OMB 0938-1148.

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Form
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IC Document
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Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction 42 - SPA Reimbursement Requirements Summary [rev 06-19-2016].docx Yes Yes Printable Only
Form CMS-10398 (#45) (Screen 1, Women) MIH Initiative Developmental Measure MIH_2015_by Women_1.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 2, Women) MIH Initiative Developmental Measure MIH_2015_by Women_2.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 3, Women) MIH Initiative Developmental Measure MIH_2015_by Women_3.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 4, Women) MIH Initiative Developmental Measure MIH_2015_by Women_4.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 5, Women) MIH Initiative Developmental Measure MIH_2015_by Women_5.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 6, Women) MIH Initiative Developmental Measure MIH_2015_by Women_6.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 1, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_1.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 2, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_2.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 3, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_3.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 4, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_4.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 5, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_5.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 6, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_6.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 7, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_7.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 8, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_8.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 9, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_9.pdf Yes Yes Fillable Printable
Form CMS-10398 (#45) (Screen 10, Postpartum Women) MIH Initiative Developmental Measure MIH_2015_Postpartum Women_10.pdf Yes Yes Fillable Printable
Instruction 47 - Health Homes Quality Measures Consolidated IG [rev 06-20-2016 by OSORA PRA].pdf Yes Yes Printable Only

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 198 0 198 0 0 0
Annual IC Time Burden (Hours) 18,112 0 18,112 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
#42 - Supporting Statement (Covered Outpatient Drugs) 42 - Supporting Statement [rev 06-19-2016 by OSORA PRA].docx 06/20/2016
45 - Supporting Statement (Maternal and Infant Health Quality) 45 - Maternal and Infant Health Quality Supporting Statement [rev 06-19-2016 by OSORA PRA].docx 06/20/2016
47 - Supporting Statement (Health Home Core Sets) 47 - Health Home Core Sets Supporting Statement [rev 06-19-2016 by OSORA PRA].docx 06/20/2016
Bundled Burden Summary Bundled Burden Table (06-20-2016).xlsx 06/20/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.