Information Collection

Medicare Disenrollee Survey - MA (CMS-10316)

IC 207675 under ICR 201307-0938-003 · OMB 0938-1113.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1113 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10316 Medicare Disenrollee Survey - MA (CMS-10316)	Form
CMS-10316 Medicare Disenrollee Survey - MA Attachment 5 - MA Only Survey.docx	Form
Attachment 1 - PRE NOTIFICATION LETTERS.docx Attachment 1 - PRE NOTIFICATION LETTERS	IC Document
Attachment 2 - SURVEY COVER LETTERS.docx Attachment 2 - SURVEY COVER LETTERS	IC Document

IC Title:

Medicare Disenrollee Survey - MA (CMS-10316)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.156

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	CMS-10316	Medicare Disenrollee Survey - MA	Attachment 5 - MA Only Survey.docx		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,870

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,870	6,870
Annual IC Time Burden (Hours)	1,443	1,443
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 1 - PRE NOTIFICATION LETTERS	Attachment 1 - PRE NOTIFICATION LETTERS.docx	07/08/2013
Attachment 2 - SURVEY COVER LETTERS	Attachment 2 - SURVEY COVER LETTERS.docx	07/08/2013

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