Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Data Submission New 150 675 0 Form Form #4
Data Use Agreement New 150 8 0 Form and Instruction Form #2
Eligibility Form New 150 8 0 Form Form #1
Medical Office Information Form New 1500 125 0 Form Form #3
Total burden requested under this ICR: 1950 816 0  
To view an IC, click on IC Title