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Pharmacies questionnaire
Medical Expenditure Panel Survey - Household and Medical Provider Components
OMB: 0935-0118
IC ID: 191107
OMB.report
HHS/AHRQ
OMB 0935-0118
ICR 202401-0935-001
IC 191107
( )
⚠️ Notice: This information collection may be referencing outdated material.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 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 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 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 99 MPC Pharmacy Letters.docx
Attachment 99 – MPC Pharmacy Provider Letters, Email Templates, and Other Documents
IC Document
Information Collection (IC) Details
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