View Information Collection (IC)

View Information Collection (IC)

Separately billing doctors 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 87 Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire.docx Yes Yes Fillable Fileable

Health Immunization Management

 

12,397 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 42,894 0 0 0 0 42,894
Annual IC Time Burden (Hours) 9,294 0 0 0 0 9,294
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment 84 – MPC Separately Billing Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated Attachment 84 MPC SBD_Fax_AF_Packet.doc 09/11/2015
Attachment 85 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated Attachment 85 MPC SBD_Phone_AF_Packet.doc 09/11/2015
Attachment 86 – MPC Separately Billing Doctor Provider Overflow Patient List Attachment 86 MPC SBD_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.