Information Collection

Pharmacies questionnaire

IC 191107 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 98 Pharmacies questionnaire	Form and Instruction
Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire Attachment 98 – MPC Pharmacy Provider Questionnaire.docx	Form and Instruction
Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire Attachment 98 – MPC Pharmacy Provider Questionnaire.docx	Form and Instruction
Attachment 95 MPC Pharmacy_Fax_AF_Packet.doc Attachment 95 – MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated	IC Document
Attachment 95 MPC Pharmacy_Fax_AF_Packet.doc Attachment 95 – MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated	IC Document
Attachment 96 MPC Pharmacy_Phone_AF_Packet.doc Attachment 96 – MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated	IC Document
Attachment 96 MPC Pharmacy_Phone_AF_Packet.doc Attachment 96 – MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated	IC Document
Attachment 97 MPC Pharmacy_Overflow_Patient_List.docx Attachment 97 – MPC Pharmacy Provider Overflow Patient List	IC Document
Attachment 97 MPC Pharmacy_Overflow_Patient_List.docx Attachment 97 – MPC Pharmacy Provider Overflow Patient List	IC Document
Attachment 98 MPC DME AF_Packet.docx Attachment 98 – MPC Durable Medical Equipment Provider Authorization Form Package	IC Document
Attachment 98 MPC DME AF_Packet.docx Attachment 98 – MPC Durable Medical Equipment Provider Authorization Form Package	IC Document
Attachment 99 MPC Pharmacy Letters.docx Attachment 99 – MPC Pharmacy Provider Letters, Email Templates, and Other Documents	IC Document
Attachment 99 MPC Pharmacy Letters.docx Attachment 99 – MPC Pharmacy Provider Letters, Email Templates, and Other Documents	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Pharmacies questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Attachment 98	Attachment 98 â MPC Pharmacy Provider Questionnaire	Attachment 98 â MPC Pharmacy Provider Questionnaire.docx		Yes	Yes	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: 9,079

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	341,370	321,167	20,203
Annual IC Time Burden (Hours)	17,069	16,059	1,010
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 95 â MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated	Attachment 95 MPC Pharmacy_Fax_AF_Packet.doc	09/14/2015
Attachment 96 â MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 96 MPC Pharmacy_Phone_AF_Packet.doc	09/14/2015
Attachment 97 â MPC Pharmacy Provider Overflow Patient List	Attachment 97 MPC Pharmacy_Overflow_Patient_List.docx	09/14/2015
Attachment 98 â MPC Durable Medical Equipment Provider Authorization Form Package	Attachment 98 MPC DME AF_Packet.docx	09/14/2015
Attachment 99 â MPC Pharmacy Provider Letters, Email Templates, and Other Documents	Attachment 99 MPC Pharmacy Letters.docx	09/14/2015

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