Information Collection

Business or other for-profit

IC 241110 under ICR 202504-3060-005 · OMB 3060-1271.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Business or other for-profit	Form
COVID-19 Telehealth Program Application Form Business or other for-profit	Form
COVID-19 Telehealth Request for Reimbursement Form Business or other for-profit	Form
Post-Commitment Request Form Business or other for-profit	Form
COVID-19 Telehealth Program Application Filing Instructions.pdf	Instruction
COVID-19 Telehealth Program Application Filing Instructions.pdf	Instruction
Request for Reimbursement Filing Instructions.pdf	Instruction
Request for Reimbursement Filing Instructions.pdf	Instruction
COVID-19 Telehealth Program Application Form COVID-19 Telehealth Program Application.pdf	Form
COVID-19 Telehealth Program Application Form COVID-19 Telehealth Program Application.pdf	Form
COVID-19 Telehealth Request for Reimbursement Form Request for Reimbursement Form.pdf	Form
COVID-19 Telehealth Request for Reimbursement Form Request for Reimbursement Form.pdf	Form
Post-Commitment Request Form Post-Commitment Request Form (Sept 2024).pdf	Form
Post-Commitment Request Form Post-Commitment Request Form (Sept 2024).pdf	Form

IC Title:

Agency IC Tracking Number:

WCB

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Yes	Yes	Fillable Fileable Signable
Instruction		Yes	Yes	Fillable Printable
Form	N/A	Yes	Yes	Fillable Fileable Signable
Instruction		Yes	Yes	Fillable Printable
Form	N/A	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,403

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	11,517	11,517
Annual IC Time Burden (Hours)	65,929	65,929
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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