Information Collection

Patient Records

IC 216391 under ICR 201807-0938-016 · OMB 0938-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 Patient Records	Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx	Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) Attachment B - CATI Questionnaire [07-31-2018].docx	Form
CMS-10500 OAS CAHPS (Web Survey Screenshots) Attachment C - Web Questionnaire [07-31-2018].docx	Form and Instruction
OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx Cover Letters	IC Document
OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx Letter Invitation for Web Survey	IC Document
OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_1st Contact.docx E-mail Invitation for Web Survey (1st Contact)	IC Document
OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation for Web Survey (Reminder)	IC Document

IC Title:

Patient Records

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-10500	OAS CAHPS (Mail Survey)	OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx	No		Fillable Fileable
Form	CMS-10500	OAS CAHPS (Telephone Script)	Attachment B - CATI Questionnaire [07-31-2018].docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Web Survey Screenshots)	Attachment C - Web Questionnaire [07-31-2018].docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,174

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,174	-7,289	9,463
Annual IC Time Burden (Hours)	72,131	-249,611	321,742
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letters	OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx	07/31/2018
Letter Invitation for Web Survey	OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx	07/31/2018
E-mail Invitation for Web Survey (1st Contact)	OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_1st Contact.docx	07/31/2018
E-mail Invitation for Web Survey (Reminder)	OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx	07/31/2018

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