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Federal forms, ICRs, and supporting documents

Information Collection

Title Data Collection for the Evaluation of the Medicare Patient Intravenous Immunoglobulin Demonstration Project

IC 221301 under ICR 201604-0938-015 · OMB 0938-1316.

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

View Information Collection (IC)

Title Data Collection for the Evaluation of the Medicare Patient Intravenous Immunoglobulin Demonstration Project
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10600 Screener and Interview Guide IVIG-PRA-Package-AppendixA-Interview11-14-15.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10600 Draft Survey Form A SPANISH Draft_Survey_Form_A_highlighted.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10600 Spanish Draft Survey Form B SPANISH Draft_Survey_Form_B_highlighted.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,941 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   50 %

  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 2,941 0 2,941 0 0 0
Annual IC Time Burden (Hours) 1,711 0 1,711 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Appendix C. Applicable Codes for Target Population of Medicare Beneficiaries with PIDD IVIG-PRA-PackageAppendixC-HCPCS&ICD9Codes-11-14-15.pdf 04/29/2016
Survey English Cover letters IVIG-PRA-Package-AppendixB-Survey-12-16-15.pdf 04/29/2016
Spanish Pre-notification Letter SPANISH PRA_Final_Prenotification_Letter.pdf 04/29/2016
Spanish Cover Letter SPANISHPRA-Final-Cover-Letter.pdf 04/29/2016
Spanish Reminder Letter SPANISHPRA-Final-Reminder-Letter.pdf 04/29/2016
Spanish reminder postcard SPANISHPRA-Final-Reminder-postcard.pdf 04/29/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.