Survey: Rounds 1 and 2

SUPPORT for Patients and Communities Act Section 1003 Demonstration Evaluation (CMS-10786)

Documents and Forms

Document Name Document Type
Form CMS-10786 Survey: Rounds 1 and 2 Form and Instruction
SUPPORT Act 1003 Provider Survey _Crosswalk.xlsx Other-Crosswalk: Survey
SUPPORT Act 1003 Provider Survey _Crosswalk.xlsx Other-Crosswalk: Survey
CMS-10786 Survey of Medicaid Opioid Use Disorder Treatment Provide providersurvey_SUPPORTAct1003.pdf Form and Instruction
CMS-10786 Survey of Medicaid Opioid Use Disorder Treatment Provide providersurvey_SUPPORTAct1003.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Survey: Rounds 1 and 2	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-10786	Survey of Medicaid Opioid Use Disorder Treatment Providers	providersurvey_SUPPORTAct1003.pdf		Yes	Yes	Fillable Fileable
Other-Crosswalk: Survey			SUPPORT Act 1003 Provider Survey _Crosswalk.xlsx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28,670	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	28,670	28,670
Annual IC Time Burden (Hours)	7,168	7,168
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.