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⚠️ Notice: This information collection may be referencing outdated material.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-10393 Beneficiary Appeals Survey Bene Survey - Appeals_508.pdf Form and Instruction
CMS-10393 Beneficiary Complaint Survey Bene Survey - Complaints_508.pdf Form and Instruction

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10393	Bene Appeals Survey	Bene Survey Appeals (SP) - v1 51512.pdf	No	No	Paper Only
Form and Instruction	CMS-10393	Beneficiary Appeals Survey	Bene Survey - Appeals_508.pdf	No		Paper Only
Form and Instruction	CMS-10393	Beneficiary Complaint Survey	Bene Survey - Complaints_508.pdf	No		Paper Only
Form	CMS-10393	Bene Complaint Survey	Bene Survey Complaint (SP) - v1 51512.pdf	Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16,010	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	Previously Approved
Annual Number of Responses for this IC	16,010	-51,990	68,000
Annual IC Time Burden (Hours)	4,003	-12,997	17,000
Annual IC Cost Burden (Dollars)	20,013	-64,987	85,000

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.