Information Collection

Telehealth Store and Forward Result

IC 266324 under ICR 202503-2900-010 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2900-0876 Teleheal Telehealth Store and Forward Result	Form and Instruction
Form 2900-0876 Teleheal 2900-0876 Telehealth Store and Forward Result Telehealth Store and Forward Result	Form and Instruction
2900-0876 Teleheal 2900-0876 Telehealth Store and Forward Result Wireframe Telehealth Store & Forward Result Survey UPDATED.docx	Form and Instruction
2900-0876 Teleheal 2900-0876 Telehealth Store and Forward Result Wireframe Telehealth Store & Forward Result Survey UPDATED.docx	Form and Instruction
ICR Template_A11 Section 280 Clearance Telehealth SFT.pdf Telehealth Store and Forward Result	IC Document
ICR Template_A11 Section 280 Clearance Telehealth SFT.pdf Telehealth Store and Forward Result	IC Document

IC Title:

Telehealth Store and Forward Result

Agency IC Tracking Number:

2900-0876 SFT Visit

IC Status: Unchanged

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	2900-0876 Telehealth Store and Forward Result				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	6,667	6,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Telehealth Store and Forward Result		03/26/2024

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

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