CAHPS for MIPS Survey Vendor Application

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.