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

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.