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Home Care Providers Event Form
Medical Expenditure Panel Survey - Household and Medical Provider Components
OMB: 0935-0118
IC ID: 191101
OMB.report
HHS/AHRQ
OMB 0935-0118
ICR 202401-0935-001
IC 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⚠️ Notice: This information collection may be referencing outdated material.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
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 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
Information Collection (IC) Details
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