Information Collection

CAHPS for MIPS Survey Beneficiary Participation

IC 206234 under ICR 201807-0938-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Beneficiary Participation	Form
Appendix C 2019_survey_initial_cover_letter_english.docx	Instruction
Appendix D 2019_survey_second_cover_letter_english.docx	Instruction
CMS-10450 Attachment B: Mail Survey Appendix B 2019_mail_survey for PRA package 2018-06-27.docx	Form
CMS-10450 Appendix E: CATI Script Appendix E 2019_CAHPS_for_MIPS_CATI_Script 2018-06-27.docx	Form and Instruction

IC Title:

CAHPS for MIPS Survey Beneficiary Participation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.1330 and 414.1335

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	CMS-10450	Attachment B: Mail Survey	Appendix B 2019_mail_survey for PRA package 2018-06-27.docx	Yes	Yes	Fillable Fileable
Instruction			Appendix C 2019_survey_initial_cover_letter_english.docx	Yes	Yes	Fillable Fileable
Instruction			Appendix D 2019_survey_second_cover_letter_english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Appendix E: CATI Script	Appendix E 2019_CAHPS_for_MIPS_CATI_Script 2018-06-27.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 65,793

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	65,793	-66,514	132,307
Annual IC Time Burden (Hours)	14,145	-14,963	29,108
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.