Hospitals questionnaire

Medical Expenditure Panel Survey - Household and Medical Provider Components

OMB: 0935-0118

IC ID: 191105

⚠️ Notice: This information collection may be referencing outdated material.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 91 Hospitals questionnaire Form and Instruction
Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire Attachment 91 – MPC Hospital Provider Questionnaire.docx Form and Instruction
Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire Attachment 91 – MPC Hospital Provider Questionnaire.docx Form and Instruction
Attachment 88 MPC Hospital_MRPA_AF_Packet.doc Attachment 88 – MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records IC Document
Attachment 88 MPC Hospital_MRPA_AF_Packet.doc Attachment 88 – MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records IC Document
Attachment 89 MPC Hospital_MR_AF_Packet.doc Attachment 89 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records IC Document
Attachment 89 MPC Hospital_MR_AF_Packet.doc Attachment 89 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records IC Document
Attachment 90 MPC Hospital_PA_AF_Packet.doc Attachment 90 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records IC Document
Attachment 90 MPC Hospital_PA_AF_Packet.doc Attachment 90 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records IC Document
Attachment 91 MPC Hospital_Overflow_Patient_List.docx Attachment 91 – MPC Hospital Provider Overflow Patient List IC Document
Attachment 91 MPC Hospital_Overflow_Patient_List.docx Attachment 91 – MPC Hospital Provider Overflow Patient List IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospitals 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 91	Attachment 91 – MPC Hospital Provider Questionnaire	Attachment 91 – MPC Hospital Provider Questionnaire.docx		No		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: 8,302	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	62,265	44,954	17,311
Annual IC Time Burden (Hours)	3,113	516	2,597
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 88 – MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records	Attachment 88 MPC Hospital_MRPA_AF_Packet.doc	09/14/2015
Attachment 89 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records	Attachment 89 MPC Hospital_MR_AF_Packet.doc	09/14/2015
Attachment 90 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records	Attachment 90 MPC Hospital_PA_AF_Packet.doc	09/14/2015
Attachment 91 – MPC Hospital Provider Overflow Patient List	Attachment 91 MPC Hospital_Overflow_Patient_List.docx	09/14/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.