Information Collection

CAHPS for MIPS Survey Beneficiary Participation

IC 206234 under ICR 201708-0938-001 · OMB 0938-1222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10450 CAHPS for MIPS Survey Beneficiary Participation	Form
Appendix C 2018_CAHPS_ for_MIPS_Initial _Cover_Letter_English.docx	Instruction
Appendix D 2018_CAHPS_for_MIPS_ Second_Cover_Letter_English.docx	Instruction
CMS-10450 Attachment B: Mail Survey Appendix B 2018_CAHPS_for_MIPS_Mail Survey.docx	Form
CMS-10450 Appendix E: CATI Script Appendix E 2018_CAHPS_for_MIPS_CATI_Script.docx	Form and Instruction
Appendix A CAHPS for MIPS Crosswalk 2017-6-8.docx Appendix A: Crosswalk	IC Document

IC Title:

CAHPS for MIPS Survey Beneficiary Participation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.1330 and 414.1335

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-10450	Attachment B: Mail Survey	Appendix B 2018_CAHPS_for_MIPS_Mail Survey.docx	Yes	Yes	Fillable Fileable
Instruction			Appendix C 2018_CAHPS_ for_MIPS_Initial _Cover_Letter_English.docx	Yes	Yes	Fillable Fileable
Instruction			Appendix D 2018_CAHPS_for_MIPS_ Second_Cover_Letter_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Appendix E: CATI Script	Appendix E 2018_CAHPS_for_MIPS_CATI_Script.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 132,307

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	132,307	0	132,307
Annual IC Time Burden (Hours)	29,108	-14,553	43,661
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix A: Crosswalk	Appendix A CAHPS for MIPS Crosswalk 2017-6-8.docx	08/01/2017

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