Information Collection

Prepare and Transmit EHR for Inpatient and Ambulatory

IC 186285 under ICR 201901-0920-008 · OMB 0920-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0212 Prepare and Transmit EHR for Inpatient and Ambulatory	Form and Instruction
0920-0212 EHR for Inpatient and Ambulatory (quarterly) Att L - Qtr Data Trans of EHR Data.doc	Form and Instruction

IC Title:

Prepare and Transmit EHR for Inpatient and Ambulatory

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	0920-0212	EHR for Inpatient and Ambulatory (quarterly)	Att L - Qtr Data Trans of EHR Data.doc	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 199

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	796	396	400
Annual IC Time Burden (Hours)	796	396	400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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