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Federal forms, ICRs, and supporting documents

Information Collection

12th SOW Patient Activation Assessment (CMS-10723)

IC 257110 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

12th SOW Patient Activation Assessment (CMS-10723)
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10723 CMS-10723.Patient Activation Assessment CMS-10723.Patient Activation Assessment.docx Yes Yes Fillable Fileable

Health Health Care Services

 

100,000 0
   
Individuals or Households
 
   0 %

  Requested 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 100,000 0 100,000 0 0 0
Annual IC Time Burden (Hours) 3,333 0 3,333 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10723.Patient Activation Survey Generic Submission Request CMS-10723.Patient Activation Survey Generic Submission Request.docx 11/25/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.