Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs

Documents and Forms

Document Name Document Type
Form CMS-10194 Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs Form and Instruction
CMS-10194 SNP-OMB Appx C Focus Group Bene Form CMS-10194 REVISED SNP-OMB Appx C FocusGroupBeneForm.doc Form and Instruction
CMS-10194 SNP-OMB Appx C FocusGroupBeneForm SNP-OMB Appx C FocusGroupBeneForm.pdf Form and Instruction
CMS-10194 FocuGroupModeratorGuide SNP-OMB Appx B FocuGroupModeratorGuide.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	Agency IC Tracking Number:

Is this a Common Form? No		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	CMS-10194	SNP-OMB Appx C FocusGroupBeneForm	SNP-OMB Appx C FocusGroupBeneForm.pdf	No	No	Paper Only
Form and Instruction	CMS-10194	FocuGroupModeratorGuide	SNP-OMB Appx B FocuGroupModeratorGuide.pdf	No	No	Paper Only
Form and Instruction	CMS-10194	SNP-OMB Appx C Focus Group Bene Form	CMS-10194 REVISED SNP-OMB Appx C FocusGroupBeneForm.doc	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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