Information Collection

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

IC 8171 under ICR 201605-0938-004 · OMB 0938-0568.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0568 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS_P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction
Global Displays_06.00.0000.xlsx	Instruction
Medicaid Display List_06.00.0000.xlsx	Instruction
Preload variables for PERS table_06.00.0000.xlsx	Instruction
State Table for help file__06.00.0000.xlsx	Instruction
CMS_P-0015A MCBS AVQ.pdf	Form and Instruction
CMS-P-0015A MCBS CLQ.pdf	Form and Instruction
CMS-P-0015A MCBS CPS.pdf	Form and Instruction
CMS-P-0015A MCBS DIQ.pdf	Form and Instruction
CMS-P-0015A MCBS DUQ.pdf	Form and Instruction
CMS-P-0015A MCBS END.pdf	Form and Instruction
CMS-P-0015A MCBS ENS.pdf	Form and Instruction
CMS-P-0015A MCBS ERQ.pdf	Form and Instruction
CMS-P-0015A MCBS EXQ.pdf	Form and Instruction
CMS-P-0015A MCBS HAQ.pdf	Form and Instruction
CMS-P-0015A MCBS HFQ.pdf	Form and Instruction
CMS-P-0015A MCBS HHQ.pdf	Form and Instruction
CMS-P-0015A MCBS HHS.pdf	Form and Instruction
CMS-P-0015A MCBS HIQ.pdf	Form and Instruction
CMS-P-0015A MCBS HIS.pdf	Form and Instruction
CMS-P-0015A MCBS IAQ.pdf	Form and Instruction
CMS-P-0015A MCBS INQ.pdf	Form and Instruction
CMS-P-0015A MCBS IPQ.pdf	Form and Instruction
CMS-P-0015A MCBS IUQ.pdf	Form and Instruction
CMS-P-0015A MCBS KNQ.pdf	Form and Instruction
CMS-P-0015A MCBS MBQ.pdf	Form and Instruction
CMS-P-0015A MCBS MPQ.pdf	Form and Instruction
CMS-P-0015A MCBS NAQ.pdf	Form and Instruction
CMS-P-0015A MCBS NSQ.pdf	Form and Instruction
CMS-P-0015A MCBS OMQ.pdf	Form and Instruction
CMS-P-0015A MCBS OPQ.pdf	Form and Instruction
CMS-P-0015A MCBS PAQ.pdf	Form and Instruction
CMS-P-0015A MCBS PMQ.pdf	Form and Instruction
CMS-P-0015A MCBS PMS.pdf	Form and Instruction
CMS-P-0015A MCBS PSQ.pdf	Form and Instruction
CMS-P-0015A MCBS PVQ.pdf	Form and Instruction
CMS-P-0015A MCBS R76 Showcards_Combined_08.03.16.pdf	Form and Instruction
CMS-P-0015A MCBS RXQ.pdf	Form and Instruction
CMS-P-0015A MCBS SCQ.pdf	Form and Instruction
CMS-P-0015A MCBS STQ.pdf	Form and Instruction
CMS-P-0015A MCBS USQ.pdf	Form and Instruction
CMS-P-0015A MCBS Attachment 5 Facility Eligibility Screener.pdf	Form and Instruction
CMS-P-0015A MCBS Attachment 6 Facility Showcards.pdf	Form and Instruction
CMS-P-0015A MCBS R69_BQF.docx	Form and Instruction
CMS-P-0015A MCBS R69_BQM.docx	Form and Instruction
CMS-P-0015A MCBS R69_BRF.docx	Form and Instruction
CMS-P-0015A MCBS R69_EXF.docx	Form and Instruction
CMS-P-0015A MCBS R69_FQF.docx	Form and Instruction
CMS-P-0015A MCBS R69_FQM.docx	Form and Instruction
CMS-P-0015A MCBS R69_HSF.docx	Form and Instruction
CMS-P-0015A MCBS R69_INF.docx	Form and Instruction
CMS-P-0015A MCBS R69_IRF.docx	Form and Instruction
CMS-P-0015A MCBS R69_NVF.docx	Form and Instruction
CMS-P-0015A MCBS R69_PMF.docx	Form and Instruction
CMS-P-0015A MCBS R69_PRF.docx	Form and Instruction
CMS-P-0015A MCBS R69_RHF.docx	Form and Instruction
CMS-P-0015A MCBS R69_RHM.docx	Form and Instruction
CMS-P-0015A MCBS R69_SRF.docx	Form and Instruction
CMS-P-0015A MCBS R69_USF.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

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 and Instruction	CMS_P-0015A	MCBS	AVQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	CLQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	CPS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	DIQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	DUQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	END.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	ENS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	ERQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	EXQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	HAQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	HFQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	HHQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	HHS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	HIQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	HIS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	IAQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	INQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	IPQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	IUQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	KNQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	MBQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	MPQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	NAQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	NSQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	OMQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	OPQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	PAQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	PMQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	PMS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	PSQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	PVQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R76 Showcards_Combined_08.03.16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	RXQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	SCQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	STQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	USQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	Attachment 5 Facility Eligibility Screener.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	Attachment 6 Facility Showcards.pdf	Yes	Yes	Fillable Fileable
Instruction			Global Displays_06.00.0000.xlsx	Yes	Yes	Fillable Fileable
Instruction			Medicaid Display List_06.00.0000.xlsx	Yes	Yes	Fillable Fileable
Instruction			Preload variables for PERS table_06.00.0000.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_BQF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_BQM.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_BRF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_EXF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_FQF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_FQM.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_HSF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_INF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_IRF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_NVF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_PMF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_PRF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_RHF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_RHM.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_SRF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	MCBS	R69_USF.docx	Yes	Yes	Fillable Fileable
Instruction			State Table for help file__06.00.0000.xlsx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,550

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	49,650	0	49,650
Annual IC Time Burden (Hours)	60,103	1,653	58,450
Annual IC Cost Burden (Dollars)	0	0	0

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.