Survey of Medicare Beneficiaries

Physician Quality Reporting System and the Electronic Prescribing Incentive Program

Documents and Forms

Document Name Document Type
Form CMS-10482 Survey of Medicare Beneficiaries Form and Instruction
CMS-10482 Attachment D - Medicare Beneficiaries Survey and Corresp Attachment_D.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Survey of Medicare Beneficiaries	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10482	Attachment D - Medicare Beneficiaries Survey and Correspondence	Attachment_D.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,200	4,200
Annual IC Time Burden (Hours)	2,100	2,100
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.