Information Collection

Hospitals questionnaire

IC 191105 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 91 Hospitals questionnaire	Form and Instruction
Form Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire Hospitals questionnaire	Form and Instruction
Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire Attachment 91 – MPC Hospital Provider Questionnaire.docx	Form and Instruction
Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire Attachment 91 – MPC Hospital Provider Questionnaire.docx	Form and Instruction
Attachment 88 MPC Hospital_MRPA_AF_Packet.doc Attachment 88 – MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records	IC Document
Attachment 88 MPC Hospital_MRPA_AF_Packet.doc Attachment 88 – MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records	IC Document
Attachment 89 MPC Hospital_MR_AF_Packet.doc Attachment 89 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records	IC Document
Attachment 89 MPC Hospital_MR_AF_Packet.doc Attachment 89 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records	IC Document
Attachment 90 MPC Hospital_PA_AF_Packet.doc Attachment 90 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records	IC Document
Attachment 90 MPC Hospital_PA_AF_Packet.doc Attachment 90 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records	IC Document
Attachment 91 MPC Hospital_Overflow_Patient_List.docx Attachment 91 – MPC Hospital Provider Overflow Patient List	IC Document
Attachment 91 MPC Hospital_Overflow_Patient_List.docx Attachment 91 – MPC Hospital Provider Overflow Patient List	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Hospitals questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	Attachment 91				No		Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,310

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: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	17,311	17,311
Annual IC Time Burden (Hours)	2,597	2,597
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 88 â MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records		09/14/2015
Attachment 89 â MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records		09/14/2015
Attachment 90 â MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records		09/14/2015
Attachment 91 â MPC Hospital Provider Overflow Patient List		09/14/2015

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

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