Business or other for-profit

Promoting Telehealth for Low-Income Consumers; COVID-19 Telehealth Program

OMB: 3060-1271

IC ID: 241110

Information Collection (IC) Details

View Information Collection (IC)

Business or other for-profit WCB
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form N/A COVID-19 Telehealth Program Application Form Attachment 1 - COVID-19 Telehealth Program Application Form 8.20 (003) (1).pdf Yes Yes Fillable Fileable Signable
Instruction Attachment 2 - COVID-19 Telehealth Program Application Filing Instructions 8.17.pdf Yes Yes Fillable Printable
Form N/A COVID-19 Telehealth Request for Reimbursement Form Attachment 3 covid-19-telehealth-request-for-reimbursement-form 8.20 (002).pdf Yes Yes Fillable Fileable Signable
Instruction Attachment 4 - COVID-19 Telehealth Program Request for Reimbursement Filing Instructions (002).pdf Yes Yes Fillable Printable
Other-Post Program Report Template C-19 Post-Program Report Template 12.28.20.docx Yes Yes Fillable Fileable Signable

Health Health Care Services

 

2,433 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  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 11,541 0 0 0 0 11,541
Annual IC Time Burden (Hours) 66,115 0 0 0 0 66,115
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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