Information Collection

Telemedicine

IC 243626 under ICR 202003-2900-011 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2900-0876-AB1 Telemedicine Home Continuing Patient Telemedicine	Form and Instruction
Form 2900-0876-AB2 Telemedicine Appointment Scheduling Telemedicine	Form and Instruction
Form 2900-AB3 Telemedicine At Home or Mobile Appointment Telemedicine	Form and Instruction
Form 2900-0876-AB4 Telemedicine Clinic Appointment Telemedicine	Form and Instruction
Form 2900-0876-AB5 Telemedicine Store Forward At Home or Mobile Appointment Telemedicine	Form and Instruction
Form 2900-0876-AB6 Telemedicine Store Forward Results Telemedicine	Form and Instruction
2900-0876-AB1 Telemedicine Home Continuing Patient Home TH Continuing Patient.pdf	Form and Instruction
2900-0876-AB2 Telemedicine Appointment Scheduling TH Appointment Scheduling.pdf	Form and Instruction
2900-AB3 Telemedicine At Home or Mobile Appointment TH at Home or Mobile Appointment.pdf	Form and Instruction
2900-0876-AB4 Telemedicine Clinic Appointment TH Clinic Appointment.pdf	Form and Instruction
2900-0876-AB5 Telemedicine Store Forward At Home or Mobile Appointment TH Store Forward at Home or Mobile Appointment.pdf	Form and Instruction
2900-0876-AB6 Telemedicine Store Forward Results TH Store Forward Results.pdf	Form and Instruction
Service Level Measurement - Telemedicine (001).docx Statistical Sample Plan Telemedicine	IC Document
A-11 Fast-Track Clearance Request Template_Telemedicine_.pdf Requirements Document	IC Document

IC Title:

Telemedicine

Agency IC Tracking Number:

2900-0876-AB

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	2900-0876-AB1	Telemedicine Home Continuing Patient	Home TH Continuing Patient.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB2	Telemedicine Appointment Scheduling	TH Appointment Scheduling.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-AB3	Telemedicine At Home or Mobile Appointment	TH at Home or Mobile Appointment.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB4	Telemedicine Clinic Appointment	TH Clinic Appointment.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB5	Telemedicine Store Forward At Home or Mobile Appointment	TH Store Forward at Home or Mobile Appointment.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB6	Telemedicine Store Forward Results	TH Store Forward Results.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 604,800

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	604,800	604,800
Annual IC Time Burden (Hours)	40,320	40,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Statistical Sample Plan Telemedicine	Service Level Measurement - Telemedicine (001).docx	09/18/2020
Requirements Document	A-11 Fast-Track Clearance Request Template_Telemedicine_.pdf	09/18/2020

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