BHI EB–TNP Outcome Measurement Report

Behavioral Health Integration (BHI) Evidence Based Telehealth Network Program (EB-TNP) Measures

Documents and Forms

Document Name Document Type
Form 1 BHI EB–TNP Outcome Measurement Report Form and Instruction
1 Evidence Based Telehealth Network Program (EB-TNP) Outco BHI EB TNP DCPaaS measures_approved 5-23-25_FINAL.docx Form and Instruction
2 Patient Travel Miles Saved BHI-EB DCPaaS Form 5_Modernization Measures Patient Travel Miles Saved_OAT-OGC approved 3-3-2025_FINAL.docx Form and Instruction

Information Collection (IC) Details

IC Title:	BHI EB–TNP Outcome Measurement Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	Evidence Based Telehealth Network Program (EB-TNP) Outcome Measurement Report	BHI EB TNP DCPaaS measures_approved 5-23-25_FINAL.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Patient Travel Miles Saved	BHI-EB DCPaaS Form 5_Modernization Measures Patient Travel Miles Saved_OAT-OGC approved 3-3-2025_FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 27	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: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	135	135
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.