Information Collection

Institutions (non-hospital) questionnaire

IC 191106 under ICR 202401-0935-001 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material.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 96 Institutions (non-hospital) questionnaire Form and Instruction
Attachment 96 Attachment 96 – MPC Institution Provider Questionnaire Attachment 96 – MPC Institution Provider Questionnaire.docx Form and Instruction
Attachment 96 Attachment 96 – MPC Institution Provider Questionnaire Attachment 96 – MPC Institution 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
Attachment 93 MPC Letter.docx Attachment 93 – MPC Letters, Email Templates, and Other Documents IC Document
Attachment 93 MPC Letter.docx Attachment 93 – MPC Letters, Email Templates, and Other Documents IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Institutions (non-hospital) 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 96	Attachment 96 â MPC Institution Provider Questionnaire	Attachment 96 â MPC Institution Provider Questionnaire.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 118	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	153	-85	238
Annual IC Time Burden (Hours)	8	-28	36
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 88 â 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 â 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 â 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 â MPC Hospital Provider Overflow Patient List	Attachment 91 MPC Hospital_Overflow_Patient_List.docx	09/14/2015
Attachment 93 â MPC Letters, Email Templates, and Other Documents	Attachment 93 MPC Letter.docx	09/14/2015

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