Business or other for-profit

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

OMB: 3060-1271

IC ID: 241110

Information Collection (IC) Details

View Information Collection (IC)

Business or other for-profit WCB
No Modified
Required to Obtain or Retain Benefits

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services


2,403 0
Private Sector Not-for-profit institutions, Businesses or other for-profits
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11,517 0 36 -60 0 11,541
Annual IC Time Burden (Hours) 65,929 0 294 -480 0 66,115
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 | Privacy Policy