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) Modified 81909 47780 0 Other-Samples of DDS CE Forms
Other-Arterial Doppler Evaluation With Toe
Other-Range of Motion
Other-Muscle Examination
Other-Resting Doppler Evaluation
Category I, CE f) Text and Email CE Reminder Call Script/Letter New 1175536 78369 0 Other-DCPS Scheduling Text and Email Consent Script
Other- DCPS Scheduling Text and Email Consent.pdf
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Modified 4000 1333 0 Form and Instruction N/A
Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category) Modified 2327217 581804 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) Modified 3065444 255454 0 Other-CE Appointment Notice to Claimant (Adult)
Other-Rescheduled CE Appointment Notice to Claimant- Adult
Other-Rescheduled CE Appointment Notice to Claimant- Child
Other-CE Appointment Notice to Claimant (child)
Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category) Modified 98340 8195 0 Other-Sample of state DDS Claimant Report Letter/Form
Category I, CE e) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category) and f) Text and Email CE Reminder Call Script/Letter Modified 165000 13750 0 Other- THCE Agreement Call Script - Adult .
Other- THCE Agreeement Call Script - Adult with Legal Guardian
Other- THCE Agreement Form - Adult
Other-THCE Agreement Form - Adult with Legal Guardian
Category II - MER Paper Submissions (subset of "MER Samples") category Modified 1444747 481582 0 Other-Sample of MER forms
Other-Doctor Evidence Request with Cardiac Questionnaire
Other-Doctor Evidence Request with Physical Report
Other-Doctor Evidence Request with Seizure Questionnaire
Other-Request for Speech and Language Questionnaire- Child 1-6
Other-Request for Speech and Language Questionnaire- Child 6-18
Other-Seizure Witness Questionnaire (3RD PTY)
Other-Mental Status Questionnaire - Adult (MER) (new)
Other-Mental Status Questionnaire - Adult (MER) - New
Other-Request for Third Party Contact (CLMT) - New
Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category) Modified 12659061 2531812 0 Other-ERE Transmission of "MER Samples" Category
Category III - Pain/Other Symptoms/Impairment Information - Headache Questionnaire - Adult New 50839 21183 0 Other-Headache Questionnaire (CLMT)
Category III - Pain/Other Symptoms/Impairment Information - Request for Third Party New 126577 21096 0 Other-Request for Third Party Contact
Category III - Pain/Other Symptoms/Impairment Information - Seizure Questionnaire - Adult Modified 54372 22655 0 Other-Seizure Questionnaire
Category III - Pain/Other Symptoms/Impairment Information - Seizure Witness Questionnaire – Adult New 8765 3652 0 Other-Seizure Witness Questionnaire (3RD PTY)
d) Travel time to and completion of CE New 1687077 1687077 0 Other-Credentialing
Total burden requested under this ICR: 22948884 5755742 0  
To view an IC, click on IC Title