Information Collection

Medicare Contractor Provider Satisfaction Survey (MCPSS) and Supporting Regulations in 42 CFR 421.120 and 421.122

IC 8757 under ICR 200705-0938-001 · OMB 0938-0915.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0915 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10097 Medicare Contractor Provider Satisfaction Survey (MCPSS) and Supporting Regulations in 42 CFR 421.120 and 421.122	Form and Instruction
CMS-10097 MCPSS Survey CMS-10097.ATTACHMENT 2 - SURVEY INSTRUMENT.pdf	Form and Instruction
CMS-10097 CMS-10097.Sample Cognitive Interview Protocol CMS-10097.Attachment 4 Sample cog interview protocol.pdf	Form

IC Title:

Medicare Contractor Provider Satisfaction Survey (MCPSS) and Supporting Regulations in 42 CFR 421.120 and 421.122

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 421.120 42 CFR 421.122

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10097	MCPSS Survey	CMS-10097.ATTACHMENT 2 - SURVEY INSTRUMENT.pdf		Yes	No	Fillable Fileable
Form	CMS-10097	CMS-10097.Sample Cognitive Interview Protocol	CMS-10097.Attachment 4 Sample cog interview protocol.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,279

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	24,279	3,765	20,514
Annual IC Time Burden (Hours)	8,346	1,371	6,975
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.