Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Data Submission Modified 85 85 0 Form Form #4
Data Use Agreement Modified 85 4 0 Form and Instruction Form #2
Eligibility Form Modified 85 4 0 Form Form #1
Medical Office Information Form Modified 2975 248 0 Form Form #3
Total burden requested under this ICR: 3230 341 0  
To view an IC, click on IC Title