Medicare Beneficiary and Family-Centered Satisfaction Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1177 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey Form
CMS-10393 Bene Complaint Survey Bene Survey Complaint (SP) - v1 51512.pdf Form
CMS-10393 Bene Appeals Survey Bene Survey Appeals (SP) - v1 51512.pdf Form
CMS Medicare Beneficiary Survey Revision Crosswalk 022912.docx Crosswalk IC Document
Revised Bene Survey Intro Letter_clean version.docx Revised Beneficiary Survey Intro Letter IC Document
Revised Bene Survey Intro Letter_tracked.docx Revised Beneficiary Survey Intro Letter - tracked changes IC Document
Revised Bene Survey Letter_followup_clean version.docx Revised Beneficiary Survey Follow-up Letter IC Document
Revised Bene Survey Letter_followup_tracked.docx Revised Beneficiary Survey Follow-up Letter - tracked changes IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Beneficiary and Family-Centered Satisfaction Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10393	Bene Complaint Survey	Bene Survey Complaint (SP) - v1 51512.pdf		Yes	No	Paper Only
Form	CMS-10393	Bene Appeals Survey	Bene Survey Appeals (SP) - v1 51512.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 68,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	68,000	68,000
Annual IC Time Burden (Hours)	17,000	17,000
Annual IC Cost Burden (Dollars)	85,000	85,000

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CMS Medicare Beneficiary Survey Revision Crosswalk 022912.docx	03/27/2012
Revised Beneficiary Survey Intro Letter	Revised Bene Survey Intro Letter_clean version.docx	04/30/2013
Revised Beneficiary Survey Intro Letter - tracked changes	Revised Bene Survey Intro Letter_tracked.docx	04/30/2013
Revised Beneficiary Survey Follow-up Letter	Revised Bene Survey Letter_followup_clean version.docx	04/30/2013
Revised Beneficiary Survey Follow-up Letter - tracked changes	Revised Bene Survey Letter_followup_tracked.docx	04/30/2013

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