Information Collection

Separately billing doctors questionnaire

IC 191104 under ICR 202007-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 87 Separately billing doctors questionnaire	Form and Instruction
Attachment 87 Attachment 87 – MPC Separately Billing Doctor Provider Q Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire.docx	Form and Instruction
Attachment 84 MPC SBD_Fax_AF_Packet.doc Attachment 84 – MPC Separately Billing Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated	IC Document
Attachment 85 MPC SBD_Phone_AF_Packet.doc Attachment 85 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated	IC Document
Attachment 86 MPC SBD_Overflow_Patient_List.docx Attachment 86 – MPC Separately Billing Doctor Provider Overflow Patient List	IC Document

IC Title:

Separately billing doctors questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 87	Attachment 87 â MPC Separately Billing Doctor Provider Questionnaire	Attachment 87 â MPC Separately Billing Doctor Provider Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,397

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: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	42,894	42,894
Annual IC Time Burden (Hours)	9,294	9,294
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 84 â MPC Separately Billing Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated	Attachment 84 MPC SBD_Fax_AF_Packet.doc	09/11/2015
Attachment 85 â MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 85 MPC SBD_Phone_AF_Packet.doc	09/11/2015
Attachment 86 â MPC Separately Billing Doctor Provider Overflow Patient List	Attachment 86 MPC SBD_Overflow_Patient_List.docx	09/11/2015

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