Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category) Unchanged 100000 50000 0 Other-Samples of DDS CE Forms
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Unchanged 3000 750 0 Form and Instruction N/A Sample CE Forms
Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category) Unchanged 3500000 583333 0 Other-Sample of types of information sent through ERE; electronic version of CE paper
Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category) Unchanged 2500000 208333 0 Other-Sample of Appointment Letter Included
Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category) Unchanged 1500000 125000 0 Other-Sample of state DDS Claimant Report Letter/Form
Category II - MER Paper Submissions (subset of "MER Samples") category Unchanged 500000 166667 0 Other-Sample of MER forms
Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category) Unchanged 5500000 1100000 0 Other-ERE Transmission of "MER Samples" Category
Category III - Pain/Other Symptoms/Impairment Information Unchanged 2500000 625000 0 Form Pain Questionnaire Pain Questionnaire
Total burden requested under this ICR: 16103000 2859083 0  
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