Information Collection

GenIC #47 - Health Home Core Sets

IC 235671 under ICR 201708-0938-004 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HHQM14 GenIC #47 - Health Home Core Sets	Form
HHQM1 Admin-Data-Source HHQM1 - Admin-Data-Source.pdf	Form
HHQM2 Admin-Hybrid-Data-Source HHQM2 - Admin-Hybrid-Data-Source.pdf	Form
HHQM3 Admin-Questions HHQM3 - Admin-Questions.pdf	Form
HHQM4 Admin-Screen HHQM4 - Admin-Screen.pdf	Form
HHQM5 Admin-Combined-Rates HHQM5 - Combined-Rates.pdf	Form
HHQM6 HHQM-ABA HHQM6 - HHQM-ABA.pdf	Form
HHQM7 HHQM-AMB HHQM7 - HHQM-AMB.pdf	Form
HHQM8 HHQM-CBP HHQM8 - HHQM-CBP.pdf	Form
HHQM9 HHQM-CDF HHQM9 - HHQM-CDF.pdf	Form
HHQM10 HHQM-CTR HHQM10 - HHQM-CTR.pdf	Form
HHQM11 HHQM-FUH HHQM11 - HHQM-FUH.pdf	Form
HHQM12 HHQM-IET HHQM12 - HHQM-IET.pdf	Form
HHQM13 HHQM-IU HHQM13 - HHQM-IU.pdf	Form
HHQM14 HHQM-NFU HHQM14 - HHQM-NFU.pdf	Form
HHQM15 HHQM-PCR HHQM15 - HHQM-PCR.pdf	Form
HHQM16 HHQM-PQI92 HHQM16 - HHQM-PQI92.pdf	Form
HHQM17 HHQM-SSGM HHQM17 - HHQM-SSGM.pdf	Form
HHQM18 Hybrid-Data-Source HHQM18 - Hybrid-Data-Source.pdf	Form
HHQM19 Hybrid-or-EHR HHQM19 - Hybrid-or-EHR.pdf	Form
HHQM20 If-Data-Not-Reported HHQM20 - If-Data-Not-Reported.pdf	Form
HHQM21 Technical-Assistance HHQM21 - Technical-Assitance.pdf	Form
47 - Health Home Core Sets Supporting Statement (version 2).docx Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #47 - Health Home Core Sets

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

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	HHQM14	HHQM-NFU	HHQM14 - HHQM-NFU.pdf	Yes	Yes	Fillable Fileable
Form	HHQM1	Admin-Data-Source	HHQM1 - Admin-Data-Source.pdf	Yes	Yes	Fillable Fileable
Form	HHQM2	Admin-Hybrid-Data-Source	HHQM2 - Admin-Hybrid-Data-Source.pdf	Yes	Yes	Fillable Fileable
Form	HHQM3	Admin-Questions	HHQM3 - Admin-Questions.pdf	Yes	Yes	Fillable Fileable
Form	HHQM4	Admin-Screen	HHQM4 - Admin-Screen.pdf	Yes	Yes	Fillable Fileable
Form	HHQM5	Admin-Combined-Rates	HHQM5 - Combined-Rates.pdf	Yes	Yes	Fillable Fileable
Form	HHQM6	HHQM-ABA	HHQM6 - HHQM-ABA.pdf	Yes	Yes	Fillable Fileable
Form	HHQM7	HHQM-AMB	HHQM7 - HHQM-AMB.pdf	Yes	Yes	Fillable Fileable
Form	HHQM8	HHQM-CBP	HHQM8 - HHQM-CBP.pdf	Yes	Yes	Fillable Fileable
Form	HHQM9	HHQM-CDF	HHQM9 - HHQM-CDF.pdf	Yes	Yes	Fillable Fileable
Form	HHQM10	HHQM-CTR	HHQM10 - HHQM-CTR.pdf	Yes	Yes	Fillable Fileable
Form	HHQM11	HHQM-FUH	HHQM11 - HHQM-FUH.pdf	Yes	Yes	Fillable Fileable
Form	HHQM12	HHQM-IET	HHQM12 - HHQM-IET.pdf	Yes	Yes	Fillable Fileable
Form	HHQM13	HHQM-IU	HHQM13 - HHQM-IU.pdf	Yes	Yes	Fillable Fileable
Form	HHQM15	HHQM-PCR	HHQM15 - HHQM-PCR.pdf	Yes	Yes	Fillable Fileable
Form	HHQM16	HHQM-PQI92	HHQM16 - HHQM-PQI92.pdf	Yes	Yes	Fillable Fileable
Form	HHQM17	HHQM-SSGM	HHQM17 - HHQM-SSGM.pdf	Yes	Yes	Fillable Fileable
Form	HHQM18	Hybrid-Data-Source	HHQM18 - Hybrid-Data-Source.pdf	Yes	Yes	Fillable Fileable
Form	HHQM19	Hybrid-or-EHR	HHQM19 - Hybrid-or-EHR.pdf	Yes	Yes	Fillable Fileable
Form	HHQM20	If-Data-Not-Reported	HHQM20 - If-Data-Not-Reported.pdf	Yes	Yes	Fillable Fileable
Form	HHQM21	Technical-Assistance	HHQM21 - Technical-Assitance.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	47 - Health Home Core Sets Supporting Statement (version 2).docx	04/12/2019

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