Business or other for-profit

Promoting Telehealth for Low-Income Consumers; COVID-19 Telehealth Program

⚠️ Notice: This information collection may be referencing outdated material.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
C-19 Post-Program Report Template 12.28.20.docx Other-Post Program Report Template
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

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
Other-Post Program Report Template			C-19 Post-Program Report Template 12.28.20.docx	Yes	Yes	Fillable Fileable Signable

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	Previously Approved
Annual Number of Responses for this IC	11,541	11,541
Annual IC Time Burden (Hours)	66,115	66,115
Annual IC Cost Burden (Dollars)	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.