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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #47 - Health Home Core Sets
Agency IC Tracking Number:
CMCS
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
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
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:
30
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
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
Documents for IC
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.