Information Collection

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

IC 8171 under ICR 201805-0938-015 · OMB 0938-0568.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction
CMS-P-0015A Comm2017R77KNQ Comm2017R77KNQ.pdf	Form and Instruction
CMS-P-0015A 2019CommShowcards_ForOMB30Day 2019CommShowcards_ForOMB30Day.pdf	Form and Instruction
CMS-P-0015A Comm2017R78IAQ Comm2017R78IAQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79DIQ Comm2017R79DIQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79END Comm2017R79END.pdf	Form and Instruction
CMS-P-0015A Comm2017R79ENS Comm2017R79ENS.pdf	Form and Instruction
CMS-P-0015A Comm2017R79ERQ Comm2017R79ERQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79HAQ Comm2017R79HAQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79HHQ Comm2017R79HHQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79HHS Comm2017R79HHS.pdf	Form and Instruction
CMS-P-0015A Comm2017R79INQ Comm2017R79INQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79IPQ Comm2017R79IPQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79IUQ Comm2017R79IUQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79MBQ Comm2017R79MBQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79OPQ Comm2017R79OPQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79PMQ Comm2017R79PMQ.pdf	Form and Instruction
CMS-P-0015A Comm2017R79PSQ Comm2017R79PSQ.pdf	Form and Instruction
CMS-P-0015A Comm2018R80ACQ Comm2018R80ACQ.pdf	Form and Instruction
CMS-P-0015A Comm2018R80USQ Comm2018R80USQ.pdf	Form and Instruction
CMS-P-0015A Comm2018R81RXQ Comm2018R81RXQ.pdf	Form and Instruction
CMS-P-0015A Comm2018R82HFQ Comm2018R82HFQ.pdf	Form and Instruction
CMS-P-0015A Comm2018R82NAQ Comm2018R82NAQ.pdf	Form and Instruction
CMS-P-0015A Comm2018R82SCQ Comm2018R82SCQ.pdf	Form and Instruction
CMS-P-0015A Comm2019R83CPS Comm2019R83CPS.pdf	Form and Instruction
CMS-P-0015A Comm2019R83DVH Comm2019R83DVH.pdf	Form and Instruction
CMS-P-0015A Comm2019R83HIQ Comm2019R83HIQ.pdf	Form and Instruction
CMS-P-0015A Comm2019R83MPQ Comm2019R83MPQ.pdf	Form and Instruction
CMS-P-0015A Comm2019R83NSQ Comm2019R83NSQ.pdf	Form and Instruction
CMS-P-0015A Comm2019R83OMQ Comm2019R83OMQ.pdf	Form and Instruction
CMS-P-0015A Comm2019R83STQ Comm2019R83STQ.pdf	Form and Instruction
CMS-P-0015A Comm2019R84CPQ Comm2019R84CPQ.pdf	Form and Instruction
CMS-P-0015A Comm2019R85PVQ Comm2019R85PVQ.pdf	Form and Instruction
CMS-P-0015A Attachment 4 Facility Screener Attachment 4 Facility Screener.pdf	Form and Instruction
CMS-P-0015A 2019FacilityShowcards_ForOMB 2019FacilityShowcards_ForOMB.pdf	Form and Instruction
CMS-P-0015A Fac2017R79RH Fac2017R79RH.pdf	Form and Instruction
CMS-P-0015A Fac2017R79RHM Fac2017R79RHM.pdf	Form and Instruction
CMS-P-0015A Fac2017R79US Fac2017R79US.pdf	Form and Instruction
CMS-P-0015A Fac2019R85BQ Fac2019R85BQ.pdf	Form and Instruction
CMS-P-0015A Fac2019R85BQM Fac2019R85BQM.pdf	Form and Instruction
CMS-P-0015A Fac2019R85EX Fac2019R85EX.pdf	Form and Instruction
CMS-P-0015A Fac2019R85FQ Fac2019R85FQ.pdf	Form and Instruction
CMS-P-0015A Fac2019R85FQM Fac2019R85FQM.pdf	Form and Instruction
CMS-P-0015A Fac2019R85HS Fac2019R85HS.pdf	Form and Instruction
CMS-P-0015A Fac2019R85IN Fac2019R85IN.pdf	Form and Instruction
CMS-P-0015A OMB Facility Specs Guide OMB Facility Specs Guide.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: Modified

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	CMS-P-0015A	Comm2017R77KNQ	Comm2017R77KNQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	2019CommShowcards_ForOMB30Day	2019CommShowcards_ForOMB30Day.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R78IAQ	Comm2017R78IAQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79DIQ	Comm2017R79DIQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79END	Comm2017R79END.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79ENS	Comm2017R79ENS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79ERQ	Comm2017R79ERQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79HAQ	Comm2017R79HAQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79HHQ	Comm2017R79HHQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79HHS	Comm2017R79HHS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79INQ	Comm2017R79INQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79IPQ	Comm2017R79IPQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79IUQ	Comm2017R79IUQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79MBQ	Comm2017R79MBQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79OPQ	Comm2017R79OPQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79PMQ	Comm2017R79PMQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2017R79PSQ	Comm2017R79PSQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2018R80ACQ	Comm2018R80ACQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2018R80USQ	Comm2018R80USQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2018R81RXQ	Comm2018R81RXQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2018R82HFQ	Comm2018R82HFQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2018R82NAQ	Comm2018R82NAQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2018R82SCQ	Comm2018R82SCQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R83CPS	Comm2019R83CPS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R83DVH	Comm2019R83DVH.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R83HIQ	Comm2019R83HIQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R83MPQ	Comm2019R83MPQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R83NSQ	Comm2019R83NSQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R83OMQ	Comm2019R83OMQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R83STQ	Comm2019R83STQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R84CPQ	Comm2019R84CPQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Comm2019R85PVQ	Comm2019R85PVQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Attachment 4 Facility Screener	Attachment 4 Facility Screener.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	2019FacilityShowcards_ForOMB	2019FacilityShowcards_ForOMB.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2017R79RH	Fac2017R79RH.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2017R79RHM	Fac2017R79RHM.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2017R79US	Fac2017R79US.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2019R85BQ	Fac2019R85BQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2019R85BQM	Fac2019R85BQM.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2019R85EX	Fac2019R85EX.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2019R85FQ	Fac2019R85FQ.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2019R85FQM	Fac2019R85FQM.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2019R85HS	Fac2019R85HS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	Fac2019R85IN	Fac2019R85IN.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P-0015A	OMB Facility Specs Guide	OMB Facility Specs Guide.docx	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: 43,199

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	Previously Approved
Annual Number of Responses for this IC	43,199	-6,451	49,650
Annual IC Time Burden (Hours)	44,165	-15,938	60,103
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.