Information Collection

Beneficiaries Survey

IC 220696 under ICR 201609-0938-012 · OMB 0938-1300.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1300 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10615 Beneficiaries Survey Form and Instruction
10. HIP 2.0 CoverLetter_English_16July2016 (rev 09-28-2016).docx Other-Survey Cover Letter II
11. HIP 2.0 Prenotification Letter_16July2016 (rev 09-28-2016).docx Other-Survey Prenotification Letter
12. Reminder Card_16July2016 (rev 09-28-2016).docx Other-Survey Reminder II
CMS-10615 HIP 2.0 Enrollee Beneficiary Survey (web option screensh 4.Enrollee_Web_Survey_v.2_0719_ExpDate_508.pdf Form and Instruction
CMS-10615 HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web 6.DisenrolleeWebSurvey_v.2_0719ExpDate_508.pdf Form and Instruction
CMS-10615 HIP 2.0 New Enrollee Beneficiary Survey (web option scre 5.New Enrollee Web Survey v.2 0719 ExpDate_508.pdf Form and Instruction
CMS-10615 HIP 2.0 Beneficiary Survey: Enrollees (paper) 1. THOR_HIPENR_ENG_SVY_07.20_PROOF (rev 09-28-2016).pdf Form and Instruction
CMS-10615 HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (pap 3. THOR_HIPDIS_ENG_SVY_07.20_PROOF (rev 09-28-2016).pdf Form and Instruction
CMS-10615 HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper) 2. THOR_HIPNEW_ENG_SVY_07.19_PROOF (rev 09-28-2016).pdf Form and Instruction
18. HIP2.0_BeneficiarySurveyCrosswalk_16July2016.xlsx Survey Crosswalk II IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Beneficiaries 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 and Instruction	CMS-10615	HIP 2.0 Enrollee Beneficiary Survey (web option screenshots)	4.Enrollee_Web_Survey_v.2_0719_ExpDate_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10615	HIP 2.0 New Enrollee Beneficiary Survey (web option screenshots)	5.New Enrollee Web Survey v.2 0719 ExpDate_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10615	HIP 2.0 Beneficiary Survey: Enrollees (paper)	1. THOR_HIPENR_ENG_SVY_07.20_PROOF (rev 09-28-2016).pdf	No		Paper Only
Other-Survey Cover Letter II			10. HIP 2.0 CoverLetter_English_16July2016 (rev 09-28-2016).docx	No		Paper Only
Other-Survey Reminder II			12. Reminder Card_16July2016 (rev 09-28-2016).docx	No		Paper Only
Form and Instruction	CMS-10615	HIP 2.0 Beneficiary Survey: Disenrollees & Lockouts (paper)	3. THOR_HIPDIS_ENG_SVY_07.20_PROOF (rev 09-28-2016).pdf	No		Paper Only
Form and Instruction	CMS-10615	HIP 2.0 Beneficiary Survey: New Enrollee Survey (paper)	2. THOR_HIPNEW_ENG_SVY_07.19_PROOF (rev 09-28-2016).pdf	No		Paper Only
Other-Survey Prenotification Letter II			11. HIP 2.0 Prenotification Letter_16July2016 (rev 09-28-2016).docx	No		Paper Only
Form and Instruction	CMS-10615	HIP 2.0 Disenrollee and Lockout Beneficiary Survey (web option screenshots)	6.DisenrolleeWebSurvey_v.2_0719ExpDate_508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,182	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,182	5,182
Annual IC Time Burden (Hours)	1,296	1,296
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Crosswalk II	18. HIP2.0_BeneficiarySurveyCrosswalk_16July2016.xlsx	07/20/2016

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