Information Collection

Patient Peer Mentoring Progam Application

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.