Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attachment 20 HC Adult SAQ Female Unchanged 12984 1515 0 Form and Instruction Attachment 20 Attachment 20 HC Adult SAQ Female
Form and Instruction Attachment 19 Attachment 19 HC Adult SAQ Male
Attachment 19 – HC Adult SAQ – Male Unchanged 11985 1398 0 Form and Instruction Attachment 19 Attachment 19 – HC Adult SAQ – Male
Form and Instruction Attachment 18 Attachment 18 HC Adult SAQ
Attachment C – Social and Health Experiences Self-Administered Questionnaire New 27059 3157 0 Form and Instruction Attachment C Attachment C
Authorization form for the MEPS-MPC Pharmacy Survey Unchanged 39692 1985 0 Form and Instruction Attachment 24 Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
Authorization form for the MEPS-MPC Provider Survey Unchanged 69142 3457 0 Form and Instruction Attachment 25 Attachment 25 HC Authorization Form for the MEPS MPC Provider
COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire New 13338 222 0 Form and Instruction Attachment A – COVID-19 Questions Attachment A – COVID-19 Questions
Form and Instruction Attachment B Attachment B
Diabetes Care SAQ Unchanged 2072 104 0 Form and Instruction Attachment 22 Attachment 22 -- HC Diabetes SAQ - Proxy
Form and Instruction Attachment 23 Attachment 23 -- HC Diabetes SAQ - Self
HC Adult SAQ that includes Mental Health Questions Unchanged 20476 1194 0 Form and Instruction 106a Attachment 106a.REV_Female PSAQ with Mental Health Content
Form and Instruction 106b Attachment106b.REV_Male PSAQ with Mental Health Content
Health Insurance Cost Sharing Collection- 2020 Unchanged 8135 6101 0 Form and Instruction 107a Attachment 107a.Protocol A (Medicare)
Form and Instruction 107b Attachment 107b.Protocol B (Employer)
Form and Instruction 107c Attachment 107c.Protocol C (Private with Medicare)_
Form and Instruction 107d Attachment 107d.Protocol D (Other)
Home care for health care providers questionnaire Unchanged 972 146 0 Form and Instruction Attachment 78 Attachment 78 – MPC Home Care Provider Questionnaire for Health Care Providers
Home care for non health care providers questionnaire Unchanged 11 2 0 Form and Instruction Attachment 82 Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
Hospitals questionnaire Unchanged 17311 2597 0 Form and Instruction Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire
Institutions (non-hospital) questionnaire Unchanged 238 36 0 Form and Instruction Attachment 96 Attachment 96 – MPC Institution Provider Questionnaire
MEPS-HC Core Interview Unchanged 33345 51129 0 Form and Instruction Attachment 29 Attachment 29 –HC Access to Care Section
Form and Instruction Attachment 30 Attachment 30 – HC Condition Enumeration Section
Form and Instruction Attachment 31 Attachment 31 – Attachment 31 HC Assets Section.
Form and Instruction Attachment 32 Attachment 32 – Attachment 32 HC Calendar Section
Form and Instruction Attachment 33 Attachment 33 Additional healthcare Section
Form and Instruction Attachment 34 Attachment 34 HC Closing Section
Form and Instruction Attachment 35 Attachment 35 HC Start_Restart
Form and Instruction Attachment 36 Attachment 36 HC Charge Payment Section
Form and Instruction Attachment 37 Attachment 37 HC Flat Fee Section
Form and Instruction Attachment 38 Attachment 38 – HC Child Preventive Health Supplement Section
Form and Instruction Attachment 39 Attachment 39 – HC Institutional Care Section
Form and Instruction Attachment 40 Attachment 40 – HC Dental Care Section
Form and Instruction Attachment 41 Attachment 41 – HC Event Driver Section
Form and Instruction Attachment 42 Attachment 42 – HC Employment (EM) Section
Form and Instruction Attachment 43 Attachment 43 – HC Review of Employment Information (RJ) Section
Form and Instruction Attachment 44 Attachment 44 – HC Employment Driver (OE) Section
Form and Instruction Attachment 45 Attachment 45 – HC Employment Wage (EW) Section
Form and Instruction Attachment 46 Attachment 46 – HC Emergency Room Section
Form and Instruction Attachment 47 Attachment 47 Event Roster Section
Form and Instruction Attachment 48 Attachment 48 Health Status Section
Form and Instruction Attachment 49 Attachment 49 HC Help Text
Form and Instruction Attachment 50 Attachment 50 Home Health Section
Form and Instruction Attachment 51 Attachment 51 Health Insurance (HX) Section
Form and Instruction Attachment 52 HC Attachment 52 HC Private Health Insurance Detail (HP) Section
Form and Instruction Attachment 53 Attachment 53 HC Time Covered Detail (HQ) Section
Form and Instruction Attachment 54 Attachment 54 HC Managed Care (MC) Section
Form and Instruction Attachment 55 Attachment 55 HC Old Employment Health Insurance (OE) Section
Form and Instruction Attachment 56 Attachment 56 HC Old Public Related Insurance (PR) Section
Form and Instruction Attachment 57 Attachment 57 HC Hospital Stay Section
Form and Instruction Attachment 58 Attachment 58 HC Income Section
Form and Instruction Attachment 59 Attachment 59 HC Medical Provider Section
Form and Instruction Attachment 60 Attachment 60 HC Other Medical Expense Section
Form and Instruction Attachment 61 Attachment 61 HC Outpatient Department Section
Form and Instruction Attachment 62 Attachment 62 HC Quality Supplement Section
Form and Instruction Attachment 63 Attachment 63 HC Respondent Forms Section
Form and Instruction Attachment 64 Attachment 64 HC Priority Conditions Enumeration Section
Form and Instruction Attachment 65 Attachment 65 HC Prescribed Medicines Section
Form and Instruction Attachment 66 Attachment 66 HC Provider Probes Section
Form and Instruction Attachment 67 Attachment 67 HC Provider Roster Section
Form and Instruction Attachment 68 Attachment 68 HC Reenumeration Subsection
Form and Instruction Attachment 69 Attachment 69 HC Reenumeration Subsection B
Form and Instruction Attachment 70 Attachment 70 HC RU Information Screener
Form and Instruction Attachment 71 Attachment 71 HC Event Follow Up Section
MEPS-HC Validation Interview Unchanged 4225 352 0 Form and Instruction Attachment 26 Attachment 26 HC MEPS Validation Interview
MPC Contact Guide/Screening Call Unchanged 36598 1220 0 Form and Instruction Attachment 72 Attachment 72 – MPC Hospital Contact Guide
Form and Instruction Attachment 73 Attachment 73 – MPC Office-Based Doctor Contact Guide
Form and Instruction Attachment 74 Attachment 74 – MPC Home Care Contact
Form and Instruction Attachment 75 Attachment 75 – MPC Institution Contact Guide
Form and Instruction Attachment 76 Attachment 76 – MPC Pharmacy Contact Guide
Form and Instruction Attachment 77 Attachment 77 – MPC Separate Billing Doctor Contact Guide
Office based providers questionnaire Unchanged 18497 3083 0 Form and Instruction Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Pharmacies questionnaire Unchanged 20203 1010 0 Form and Instruction Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Unchanged 200 307 0 Form and Instruction 108 Attachment 108 - Household Component Core Instrument Link
Separately billing doctors questionnaire Unchanged 42894 9294 0 Form and Instruction Attachment 87 Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
Total burden requested under this ICR: 379377 88309 0  
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