Information Collection

Medicare Beneficiary and Family-Centered Satisfaction Survey

IC 201543 under ICR 201509-0938-012 · OMB 0938-1177.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.