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 1400000 700000 0 Other-Samples of DDS CE Forms
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Unchanged 4000 1000 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 296000 49333 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 880000 73333 0 Other-Sample of Appointment Letter Included
Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category) Unchanged 450000 37500 0 Other-Sample of state DDS Claimant Report Letter/Form
Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category) New 10000 833 0 Other-Call Script
Category II - MER Paper Submissions (subset of "MER Samples") category Unchanged 3150000 1050000 0 Other-Sample of MER forms
Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category) Unchanged 9450000 1890000 0 Other-ERE Transmission of "MER Samples" Category
Category III - Pain/Other Symptoms/Impairment Information Unchanged 2100000 700000 0 Form Pain Questionnaire Pain Questionnaire
Total burden requested under this ICR: 17740000 4501999 0  
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