Information Collection

Hospitals questionnaire

IC 191105 under ICR 201808-0935-001 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 91 Hospitals questionnaire	Form and Instruction
Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire Attachment 91 – MPC Hospital Provider Questionnaire.docx	Form and Instruction
Attachment 88 MPC Hospital_MRPA_AF_Packet.doc Attachment 88 – MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records	IC Document
Attachment 89 MPC Hospital_MR_AF_Packet.doc Attachment 89 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records	IC Document
Attachment 90 MPC Hospital_PA_AF_Packet.doc Attachment 90 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records	IC Document
Attachment 91 MPC Hospital_Overflow_Patient_List.docx Attachment 91 – MPC Hospital Provider Overflow Patient List	IC Document

IC Title:

Hospitals questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Attachment 91	Attachment 91 â MPC Hospital Provider Questionnaire	Attachment 91 â MPC Hospital Provider Questionnaire.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,310

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17,311	-509	17,820
Annual IC Time Burden (Hours)	2,597	-76	2,673
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 88 â MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records	Attachment 88 MPC Hospital_MRPA_AF_Packet.doc	09/14/2015
Attachment 89 â MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records	Attachment 89 MPC Hospital_MR_AF_Packet.doc	09/14/2015
Attachment 90 â MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records	Attachment 90 MPC Hospital_PA_AF_Packet.doc	09/14/2015
Attachment 91 â MPC Hospital Provider Overflow Patient List	Attachment 91 MPC Hospital_Overflow_Patient_List.docx	09/14/2015

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