Telemedicine

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Document Name Document Type
Form 2900-0876-AB1 Telemedicine Form and Instruction
2900-0876-AB1 Telemedicine Home Continuing Patient Home TH Continuing Patient.pdf Form and Instruction
2900-0876-AB2 Telemedicine Appointment Scheduling TH Appointment Scheduling.pdf Form and Instruction
2900-AB3 Telemedicine At Home or Mobile Appointment TH at Home or Mobile Appointment.pdf Form and Instruction
2900-0876-AB4 Telemedicine Clinic Appointment TH Clinic Appointment.pdf Form and Instruction
2900-0876-AB5 Telemedicine Store Forward At Home or Mobile Appointment TH Store Forward at Home or Mobile Appointment.pdf Form and Instruction
2900-0876-AB6 Telemedicine Store Forward Results TH Store Forward Results.pdf Form and Instruction
Service Level Measurement - Telemedicine (001).docx Statistical Sample Plan Telemedicine IC Document
A-11 Fast-Track Clearance Request Template_Telemedicine_.pdf Requirements Document IC Document

Information Collection (IC) Details

IC Title:	Telemedicine	Agency IC Tracking Number:	2900-0876-AB

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2900-0876-AB1	Telemedicine Home Continuing Patient	Home TH Continuing Patient.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB2	Telemedicine Appointment Scheduling	TH Appointment Scheduling.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-AB3	Telemedicine At Home or Mobile Appointment	TH at Home or Mobile Appointment.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB4	Telemedicine Clinic Appointment	TH Clinic Appointment.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB5	Telemedicine Store Forward At Home or Mobile Appointment	TH Store Forward at Home or Mobile Appointment.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AB6	Telemedicine Store Forward Results	TH Store Forward Results.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 604,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	604,800	604,800
Annual IC Time Burden (Hours)	40,320	40,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Statistical Sample Plan Telemedicine	Service Level Measurement - Telemedicine (001).docx	09/18/2020
Requirements Document	A-11 Fast-Track Clearance Request Template_Telemedicine_.pdf	09/18/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.