Information Collection

Fee-For-Service (FFS) Survey

IC 194257 under ICR 201706-0938-003 · OMB 0938-0732.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0732 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-246 Fee-For-Service (FFS) Survey	Form and Instruction
CMS-R-246 Fee-For-Service (FFS) Survey CAHPS_FFS_Survey_2017.docx	Form and Instruction
FFS_survey_crosswalk_2017.docx Crosswalk - FFS Survey	IC Document

IC Title:

Fee-For-Service (FFS) Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.159 42 CFR 422.152(b)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-246	Fee-For-Service (FFS) Survey	CAHPS_FFS_Survey_2017.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Privacy Act of 1974: HPMS # 09-70-4004

FR Citation: 63 FR 43187

Number of Respondents: 274,950

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	274,950	0	274,950
Annual IC Time Burden (Hours)	68,738	-13,747	82,485
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - FFS Survey	FFS_survey_crosswalk_2017.docx	07/17/2017

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