GenIC #22.Medicare Telehealth Beneficiary Survey

Generic Social Marketing & Consumer Testing Research (CMS-10437)

Documents and Forms

Document Name Document Type
Form CMS-10437.GenIC #2 GenIC #22.Medicare Telehealth Beneficiary Survey Form and Instruction
CMS-10437.GenIC #2 CMS-10437.GenIC #22 - CMS Beneficiary Telemedicine Surve CMS-10437.GenIC #22 - CMS Beneficiary Telemedicine Survey- Questionnaire REV.docx Form and Instruction
CMS-10437.GenIC#22 - TelehealthBeneficiary_SupportingStatement.docx CMS-10437.GenIC#22 - TelehealthBeneficiary_SupportingStatement IC Document
CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form.docx CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form IC Document

Information Collection (IC) Details

IC Title:	GenIC #22.Medicare Telehealth Beneficiary Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10437.GenIC #22	CMS-10437.GenIC #22 - CMS Beneficiary Telemedicine Survey- Questionnaire REV.docx	CMS-10437.GenIC #22 - CMS Beneficiary Telemedicine Survey- Questionnaire REV.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10437.GenIC#22 - TelehealthBeneficiary_SupportingStatement	CMS-10437.GenIC#22 - TelehealthBeneficiary_SupportingStatement.docx	11/19/2020
CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form	CMS-10437.GenIC#22 - Telehealth Survey Study Initiation Form.docx	11/19/2020

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