Information Collection

Notice to Treat up to 100 Patients

IC 222811 under ICR 202211-0930-002 · OMB 0930-0234.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NOI Physicians 30 Notice to Treat up to 100 Patients	Form and Instruction
NOI Physicians 30 NOI Physicians 30 and 100 Waiver Attachment A-NOI Physicians 30 and 100 Waiver_30E_Clean.docx	Form and Instruction
NOI Physicians 30 NOI Physicians 30 and 100 Waiver Attachment A-NOI Physicians 30 and 100 Waiver_30E_Clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	NOI Physicians 30 and 100 Waiver	NOI Physicians 30 and 100 Waiver	Attachment A-NOI Physicians 30 and 100 Waiver_30E_Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	600	100	500
Annual IC Time Burden (Hours)	24	4	20
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.