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Federal forms, ICRs, and supporting documents

Information Collection

Non-Participant Components Annual Follow Up Health Care Provide Records Request (Annual follow-up)

IC 221033 under ICR 201604-0925-002 · OMB 0925-0216.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Non-Participant Components Annual Follow Up Health Care Provide Records Request (Annual follow-up)
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Attachment 5 Medical Record Request Attach 5 Medical Record Request.docx No   Paper Only

Health Health Care Services

 

1,155 0
   
Individuals or Households
 
   0 %

  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 1,155 0 1,155 0 0 0
Annual IC Time Burden (Hours) 289 0 289 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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