Information Collection

Designation, Planning, and Preparation

IC 219565 under ICR 202303-0906-002 · OMB 0906-0029.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0029 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form E Designation, Planning, and Preparation	Form and Instruction
Form E PCO Provider Management User Guide - Attachment E.pdf Designation, Planning, and Preparation	Form and Instruction
Form F PCO Designation Management User Guide - Attachment F.pdf Designation, Planning, and Preparation	Form and Instruction
Form G Manual for Policies and Procedures - Attachment G.pdf Designation, Planning, and Preparation	Form and Instruction
E PCO Provider Management User Guide - Attachment E.pdf PCO Provider Management User Guide - Attachment E.pdf	Form and Instruction
E PCO Provider Management User Guide - Attachment E.pdf PCO Provider Management User Guide - Attachment E.pdf	Form and Instruction
F PCO Designation Management User Guide - Attachment F.pdf PCO Designation Management User Guide - Attachment F.pdf	Form and Instruction
F PCO Designation Management User Guide - Attachment F.pdf PCO Designation Management User Guide - Attachment F.pdf	Form and Instruction
G Manual for Policies and Procedures - Attachment G.pdf Manual for Policies and Procedures - Attachment G.pdf	Form and Instruction
G Manual for Policies and Procedures - Attachment G.pdf Manual for Policies and Procedures - Attachment G.pdf	Form and Instruction

IC Title:

Designation, Planning, and Preparation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	E	Yes	Yes	Fillable Fileable
Form and Instruction	F	Yes	Yes	Fillable Fileable
Form and Instruction	G	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Previously Approved
Annual Number of Responses for this IC	2,592	2,592
Annual IC Time Burden (Hours)	20,736	20,736
Annual IC Cost Burden (Dollars)	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.

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