View Information Collection (IC)

View Information Collection (IC)

Office based providers questionnaire
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questionnaire Attachment 83 – MPC Office-Based Doctor Provider Questionnaire.docx Yes Yes Fillable Fileable

Health Immunization Management

 

11,210 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 18,497 0 0 0 0 18,497
Annual IC Time Burden (Hours) 3,083 0 0 0 0 3,083
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment 80 – MPC Office-Based Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated Attachment 80 MPC OBD_Fax_AF_Packet.doc 09/11/2015
Attachment 81 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated Attachment 81 MPC OBD_Phone_AF_Packet.doc 09/11/2015
Attachment 82 – MPC Office-Based Doctor Provider Overflow Patient List Attachment 82 MPC OBD_Overflow_Patient_List.docx 09/11/2015
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.