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

(CMS-10600) Evaluation of the Medicare Patient Intravenous Immunoglobulin Demonstration

Documents and Forms

Document Name Document Type
Form CMS-10600 Title Data Collection for the Evaluation of the Medicare Patient Intravenous Immunoglobulin Demonstration Project Form and Instruction
CMS-10600 Screener and Interview Guide IVIG-PRA-Package-AppendixA-Interview11-14-15.pdf Form and Instruction
CMS-10600 Draft Survey Form A SPANISH Draft_Survey_Form_A_highlighted.pdf Form and Instruction
CMS-10600 Spanish Draft Survey Form B SPANISH Draft_Survey_Form_B_highlighted.pdf Form and Instruction
IVIG-PRA-PackageAppendixC-HCPCS&ICD9Codes-11-14-15.pdf Appendix C. Applicable Codes for Target Population of Medicare Beneficiaries with PIDD IC Document
IVIG-PRA-Package-AppendixB-Survey-12-16-15.pdf Survey English Cover letters IC Document
SPANISH PRA_Final_Prenotification_Letter.pdf Spanish Pre-notification Letter IC Document
SPANISHPRA-Final-Cover-Letter.pdf Spanish Cover Letter IC Document
SPANISHPRA-Final-Reminder-Letter.pdf Spanish Reminder Letter IC Document
SPANISHPRA-Final-Reminder-postcard.pdf Spanish reminder postcard IC Document

Information Collection (IC) Details

IC Title:	Title Data Collection for the Evaluation of the Medicare Patient Intravenous Immunoglobulin Demonstration Project	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,941	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,941	2,941
Annual IC Time Burden (Hours)	1,711	1,711
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.