Office based providers questionnaire

Medical Expenditure Panel Survey - Household and Medical Provider Components

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form Attachment 83 Office based providers questionnaire Form and Instruction
Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questio Attachment 83 – MPC Office-Based Doctor Provider Questionnaire.docx Form and Instruction
Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questio Attachment 83 – MPC Office-Based Doctor Provider Questionnaire.docx Form and Instruction
Attachment 80 MPC OBD_Fax_AF_Packet.doc Attachment 80 – MPC Office-Based Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated IC Document
Attachment 80 MPC OBD_Fax_AF_Packet.doc Attachment 80 – MPC Office-Based Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated IC Document
Attachment 81 MPC OBD_Phone_AF_Packet.doc Attachment 81 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated IC Document
Attachment 81 MPC OBD_Phone_AF_Packet.doc Attachment 81 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated IC Document
Attachment 82 MPC OBD_Overflow_Patient_List.docx Attachment 82 – MPC Office-Based Doctor Provider Overflow Patient List IC Document
Attachment 82 MPC OBD_Overflow_Patient_List.docx Attachment 82 – MPC Office-Based Doctor Provider Overflow Patient List IC Document

Information Collection (IC) Details

IC Title:	Office based providers questionnaire	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	Attachment 83	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,950	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: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	64,285	45,788	18,497
Annual IC Time Burden (Hours)	3,214	131	3,083
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 80 – MPC Office-Based Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated	Attachment 80 MPC OBD_Fax_AF_Packet.doc	09/11/2015
Attachment 81 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 81 MPC OBD_Phone_AF_Packet.doc	09/11/2015
Attachment 82 – MPC Office-Based Doctor Provider Overflow Patient List	Attachment 82 MPC OBD_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.