Information Collection

CAHPS for MIPS Survey Vendor Application

IC 227776 under ICR 201712-0938-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Vendor Application	Form and Instruction
CMS-10450 Appendix F: Vendor Form Appendix F 2018 CAHPS for MIPS Vendor Participation Form.pdf	Form and Instruction
CMS-10450 Appendix H: Vendor Attestation Appendix H CAHPS for MIPS Vendor Attestation Statement.pdf	Form and Instruction
Appendix G Technical References.pdf Technical References	IC Document
Appendix I 2018 CAHPS for MIPS Vendor Participation Form Crosswalk.pdf Appendix I: Vendor Participation Crosswalk	IC Document

IC Title:

CAHPS for MIPS Survey Vendor Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.1400

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-10450	Appendix F: Vendor Form	Appendix F 2018 CAHPS for MIPS Vendor Participation Form.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Appendix H: Vendor Attestation	Appendix H CAHPS for MIPS Vendor Attestation Statement.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Technical References	Appendix G Technical References.pdf	12/20/2017
Appendix I: Vendor Participation Crosswalk	Appendix I 2018 CAHPS for MIPS Vendor Participation Form Crosswalk.pdf	12/20/2017

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