Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Bundle: #42 (Covered Outpatient Drugs) #45 (Maternal and Infant Health Quality) and #47 (Health Home Core Sets)
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Instruction
42 - SPA Reimbursement Requirements Summary [rev 06-19-2016].docx
Yes
Yes
Printable Only
Form
CMS-10398 (#45)
(Screen 1, Women) MIH Initiative Developmental Measure
MIH_2015_by Women_1.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 2, Women) MIH Initiative Developmental Measure
MIH_2015_by Women_2.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 3, Women) MIH Initiative Developmental Measure
MIH_2015_by Women_3.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 4, Women) MIH Initiative Developmental Measure
MIH_2015_by Women_4.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 5, Women) MIH Initiative Developmental Measure
MIH_2015_by Women_5.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 6, Women) MIH Initiative Developmental Measure
MIH_2015_by Women_6.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 1, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_1.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 2, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_2.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 3, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_3.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 4, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_4.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 5, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_5.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 6, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_6.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 7, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_7.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 8, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_8.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 9, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_9.pdf
Yes
Yes
Fillable Printable
Form
CMS-10398 (#45)
(Screen 10, Postpartum Women) MIH Initiative Developmental Measure
MIH_2015_Postpartum Women_10.pdf
Yes
Yes
Fillable Printable
Instruction
47 - Health Homes Quality Measures Consolidated IG [rev 06-20-2016 by OSORA PRA].pdf
Yes
Yes
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
56
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
198
0
198
0
0
0
Annual IC Time Burden (Hours)
18,112
0
18,112
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
#42 - Supporting Statement (Covered Outpatient Drugs)
42 - Supporting Statement [rev 06-19-2016 by OSORA PRA].docx
06/20/2016
45 - Supporting Statement (Maternal and Infant Health Quality)
45 - Maternal and Infant Health Quality Supporting Statement [rev 06-19-2016 by OSORA PRA].docx
06/20/2016
47 - Supporting Statement (Health Home Core Sets)
47 - Health Home Core Sets Supporting Statement [rev 06-19-2016 by OSORA PRA].docx
06/20/2016
Bundled Burden Summary
Bundled Burden Table (06-20-2016).xlsx
06/20/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.