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Separately billing doctors questionnaire
Medical Expenditure Panel Survey - Household and Medical Provider Components
OMB: 0935-0118
IC ID: 191104
OMB.report
HHS/AHRQ
OMB 0935-0118
ICR 202401-0935-001
IC 191104
( )
⚠️ Notice: This information collection may be referencing outdated material.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 Attachment 87
Separately billing doctors questionnaire
Form and Instruction
Attachment 87 Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire.docx
Form and Instruction
Attachment 84 MPC SBD_Fax_AF_Packet.doc
Attachment 84 – MPC Separately Billing Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated
IC Document
Attachment 85 MPC SBD_Phone_AF_Packet.doc
Attachment 85 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated
IC Document
Attachment 86 MPC SBD_Overflow_Patient_List.docx
Attachment 86 – MPC Separately Billing Doctor Provider Overflow Patient List
IC Document
Information Collection (IC) Details
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