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GenIC #47 - Health Home Core Sets CMCS
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HHQM1 Admin-Data-Source HHQM1 - Admin-Data-Source.pdf Yes Yes Fillable Fileable
Form HHQM2 Admin-Hybrid-Data-Source HHQM2 - Admin-Hybrid-Data-Source.pdf Yes Yes Fillable Fileable
Form HHQM3 Admin-Questions HHQM3 - Admin-Questions.pdf Yes Yes Fillable Fileable
Form HHQM4 Admin-Screen HHQM4 - Admin-Screen.pdf Yes Yes Fillable Fileable
Form HHQM5 Admin-Combined-Rates HHQM5 - Combined-Rates.pdf Yes Yes Fillable Fileable
Form HHQM6 HHQM-ABA HHQM6 - HHQM-ABA.pdf Yes Yes Fillable Fileable
Form HHQM7 HHQM-AMB HHQM7 - HHQM-AMB.pdf Yes Yes Fillable Fileable
Form HHQM8 HHQM-CBP HHQM8 - HHQM-CBP.pdf Yes Yes Fillable Fileable
Form HHQM9 HHQM-CDF HHQM9 - HHQM-CDF.pdf Yes Yes Fillable Fileable
Form HHQM10 HHQM-CTR HHQM10 - HHQM-CTR.pdf Yes Yes Fillable Fileable
Form HHQM11 HHQM-FUH HHQM11 - HHQM-FUH.pdf Yes Yes Fillable Fileable
Form HHQM12 HHQM-IET HHQM12 - HHQM-IET.pdf Yes Yes Fillable Fileable
Form HHQM13 HHQM-IU HHQM13 - HHQM-IU.pdf Yes Yes Fillable Fileable
Form HHQM14 HHQM-NFU HHQM14 - HHQM-NFU.pdf Yes Yes Fillable Fileable
Form HHQM15 HHQM-PCR HHQM15 - HHQM-PCR.pdf Yes Yes Fillable Fileable
Form HHQM16 HHQM-PQI92 HHQM16 - HHQM-PQI92.pdf Yes Yes Fillable Fileable
Form HHQM17 HHQM-SSGM HHQM17 - HHQM-SSGM.pdf Yes Yes Fillable Fileable
Form HHQM18 Hybrid-Data-Source HHQM18 - Hybrid-Data-Source.pdf Yes Yes Fillable Fileable
Form HHQM19 Hybrid-or-EHR HHQM19 - Hybrid-or-EHR.pdf Yes Yes Fillable Fileable
Form HHQM20 If-Data-Not-Reported HHQM20 - If-Data-Not-Reported.pdf Yes Yes Fillable Fileable
Form HHQM21 Technical-Assistance HHQM21 - Technical-Assitance.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

30 0
   
State, Local, and Tribal Governments
 
   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 30 0 30 0 0 0
Annual IC Time Burden (Hours) 1,200 0 1,200 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement 47 - Health Home Core Sets Supporting Statement (version 2).docx 04/12/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.