Information Collection

Home care for non health care providers questionnaire

IC 191102 under ICR 202209-0935-003 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Document Name Document Type
Form Attachment 82 Home care for non health care providers questionnaire Form and Instruction
Attachment 82 Attachment 82 – MPC Home Care Provider Questionnaire for Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers.docx Form and Instruction
Attachment 82 Attachment 82 – MPC Home Care Provider Questionnaire for Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers.docx Form and Instruction
Attachment 75 MPC HomeHealth_Phone_AF_Packet.doc Attachment 75 – MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated IC Document
Attachment 75 MPC HomeHealth_Phone_AF_Packet.doc Attachment 75 – MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated IC Document
Attachment 76 MPC HomeHealth_Fax_AF_Packet.doc Attachment 76 – MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated IC Document
Attachment 76 MPC HomeHealth_Fax_AF_Packet.doc Attachment 76 – MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated IC Document
Attachment 77 MPC HomeHealth_Overflow_Patient_List.docx Attachment 77 – MPC Home Care Provider Overflow Patient List IC Document
Attachment 77 MPC HomeHealth_Overflow_Patient_List.docx Attachment 77 – MPC Home Care Provider Overflow Patient List IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Home care for non health care providers questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	Attachment 82	Attachment 82 â MPC Home Care Provider Questionnaire for Non-Health Care Providers	Attachment 82 â MPC Home Care Provider Questionnaire for Non-Health Care Providers.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11	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: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	11	11
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 75 â MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 75 MPC HomeHealth_Phone_AF_Packet.doc	09/11/2015
Attachment 76 â MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated	Attachment 76 MPC HomeHealth_Fax_AF_Packet.doc	09/11/2015
Attachment 77 â MPC Home Care Provider Overflow Patient List	Attachment 77 MPC HomeHealth_Overflow_Patient_List.docx	09/11/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.