Information Collection

GenIC#22 - Medicare Telehealth Beneficiary Survey

IC 242248 under ICR 201708-0938-025 · OMB 0938-1247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS--10437.GenIC#2 GenIC#22 - Medicare Telehealth Beneficiary Survey	Form and Instruction
CMS--10437.GenIC#2 Beneficiary Telemedicine Survey- Questionnaire CMS-10437.GenIC #22 - CMS Beneficiary Telemedicine Survey- Questionnaire REV.docx	Form and Instruction
CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form.docx CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form	IC Document
CMS-10437#22 - TelehealthBeneficiary_SupportingStatement (Final-12-23-20) - clean.docx CMS-10437.GenIC#22 - TelehealthBeneficiary_SupportingStatement	IC Document

IC Title:

GenIC#22 - Medicare Telehealth Beneficiary Survey

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS--10437.GenIC#22	Beneficiary Telemedicine Survey- Questionnaire	CMS-10437.GenIC #22 - CMS Beneficiary Telemedicine Survey- Questionnaire REV.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,000	1,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form	CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form.docx	06/12/2020
CMS-10437.GenIC#22 - TelehealthBeneficiary_SupportingStatement	CMS-10437#22 - TelehealthBeneficiary_SupportingStatement (Final-12-23-20) - clean.docx	12/28/2020

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