Information Collection

Business or other for-profit

IC 241110 under ICR 202008-3060-005 · OMB 3060-1271.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1271 can be found here:

Documents and Forms

Document Name Document Type
Business or other for-profit Form
Attachment 2 - COVID-19 Telehealth Program Application Filing Instructions 8.17.pdf Instruction
Attachment 4 - COVID-19 Telehealth Program Request for Reimbursement Filing Instructions (002).pdf Instruction
COVID-19 Telehealth Program Application Form Attachment 1 - COVID-19 Telehealth Program Application Form 8.20 (003) (1).pdf Form
COVID-19 Telehealth Request for Reimbursement Form Attachment 3 covid-19-telehealth-request-for-reimbursement-form 8.20 (002).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Business or other for-profit	Agency IC Tracking Number:	WCB

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	COVID-19 Telehealth Program Application Form	Attachment 1 - COVID-19 Telehealth Program Application Form 8.20 (003) (1).pdf	Yes	Yes	Fillable Fileable Signable
Instruction			Attachment 2 - COVID-19 Telehealth Program Application Filing Instructions 8.17.pdf	Yes	Yes	Fillable Printable
Form	N/A	COVID-19 Telehealth Request for Reimbursement Form	Attachment 3 covid-19-telehealth-request-for-reimbursement-form 8.20 (002).pdf	Yes	Yes	Fillable Fileable Signable
Instruction			Attachment 4 - COVID-19 Telehealth Program Request for Reimbursement Filing Instructions (002).pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,433	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	11,541	2,201	9,340
Annual IC Time Burden (Hours)	66,115	8,340	57,775
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.