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

Medicare Current Beneficiary Survey (MCBS)

OMB: 0938-0568

IC ID: 8171

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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: Unchanged

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_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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	49,650	49,650
Annual IC Time Burden (Hours)	60,103	60,103
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.