Information Collection

Patient Peer Mentoring Progam Application

IC 249687 under ICR 202110-0938-004 · OMB 0938-1418.

Documents and Forms

Document Name Document Type
Form CMS-10768 Patient Peer Mentoring Progam Application Form and Instruction
CMS-10768 Patient Peer Mentoring Program Application PMApp_Images_508_2.pdf Form and Instruction
CMS-10768 Patient Peer Mentoring Program Application PMApp_Images_508_2.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Peer Mentoring Progam Application	Agency IC Tracking Number:

Is this a Common Form? No		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-10768	Patient Peer Mentoring Program Application	PMApp_Images_508_2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	19	19
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.