Business or other for-profit

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

Documents and Forms

Document Name Document Type
Business or other for-profit Form
COVID-19 Telehealth Program Application Filing Instructions (2).pdf Instruction
COVID-19 Telehealth Program Application Filing Instructions (2).pdf Instruction
Request for Reimbursement Filing Instructions.pdf Instruction
Request for Reimbursement Filing Instructions.pdf Instruction
Post-Commitment Request Form.docx Other-Post Program Report Template
Post-Commitment Request Form.docx Other-Post Program Report Template
COVID-19 Telehealth Program Application Form COVID-19 Telehealth Program Application.pdf Form
COVID-19 Telehealth Program Application Form COVID-19 Telehealth Program Application.pdf Form
COVID-19 Telehealth Request for Reimbursement Form Request for Reimbursement Form.pdf Form
COVID-19 Telehealth Request for Reimbursement Form Request for Reimbursement Form.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	COVID-19 Telehealth Program Application.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			COVID-19 Telehealth Program Application Filing Instructions (2).pdf	Yes	Yes	Fillable Printable
Form	N/A	COVID-19 Telehealth Request for Reimbursement Form	Request for Reimbursement Form.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			Request for Reimbursement Filing Instructions.pdf	Yes	Yes	Fillable Printable
Other-Post Program Report Template			Post-Commitment Request Form.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: 2,403	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	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	11,517	36	-60	11,541
Annual IC Time Burden (Hours)	65,929	294	-480	66,115
Annual IC Cost Burden (Dollars)	0	0	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.