Home Care Providers Event Form

Medical Expenditure Panel Survey - Household and Medical Provider Components

OMB: 0935-0118

IC ID: 191101

⚠️ Notice: This information collection may be referencing outdated material.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

2024-07-02 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form 4a Home Care Providers Event Form Form and Instruction
4a Home Health Event Form for Health Care Providers Home Health Event Form for Health Care Providers.docx Form and Instruction
4a Home Health Event Form for Health Care Providers Home Health Event Form for Health Care Providers.docx Form and Instruction
5a Home Health Event Form for Non-Health Care Providers Home Health Event Form for Non-Health Care Providers.docx Form and Instruction
5a Home Health Event Form for Non-Health Care Providers Home Health Event Form for Non-Health Care Providers.docx Form and Instruction
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 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 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 Providers Event Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	4a	Home Health Event Form for Health Care Providers	Home Health Event Form for Health Care Providers.docx		Yes	Yes	Fillable Fileable
Form and Instruction	5a	Home Health Event Form for Non-Health Care Providers	Home Health Event Form for Non-Health Care Providers.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 886	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,139	4,167	972
Annual IC Time Burden (Hours)	257	111	146
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 76 – 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 75 – MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 75 MPC HomeHealth_Phone_AF_Packet.doc	09/11/2015
Attachment 77 – 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.