Information Collection

Quarterly Patient Information Form

IC 210979 under ICR 201602-0920-007 · OMB 0920-1019.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Quarterly Patient Information Form	Form
Quarterly Patient Information Att 7a_Quarterly Patient Info Form.docx	Form
Quarterly Patient Information - screenshots Attachment 7c_Screenshots for Quarterly Patient Info forms.pdf	Form
Att 7b_Quarterly Patient Info Form Instructions.docx Quarterly Patient Information Form Instructions	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Quarterly Patient Information	Att 7a_Quarterly Patient Info Form.docx		Yes	Yes	Fillable Fileable
Form	none	Quarterly Patient Information - screenshots	Attachment 7c_Screenshots for Quarterly Patient Info forms.pdf		Yes	Yes	Fillable Fileable

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: 100 %

table that charts list of burden
	Approved	Previously Approved
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 Info Form Instructions.docx	02/17/2016

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