View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

HOPDs/ASCs Patient Records
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10500 No   Fillable Fileable
Form CMS-10500 Yes Yes Fillable Fileable
Form and Instruction CMS-10500 Yes Yes Fillable Fileable

Health Health Care Services

 

3,300 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,300 0 1,126 0 0 2,174
Annual IC Time Burden (Hours) 92,400 0 20,269 0 0 72,131
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Cover Letters 07/26/2021
Letter Invitation for Web Survey 07/26/2021
E-mail Invitation for Web Survey (1st Contact) 07/26/2021
Followup Web Survey Invitation Letter 07/26/2021
Follow up Web Survey Invitation Email 07/26/2021
Web with Mail Followup_Questionnaire Cover Letter 07/26/2021
Prenote Letter for Telephone Only 07/26/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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