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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 %

	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

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.