Information Collection

Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)

IC 238682 under ICR 201904-0938-017 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10720 Overall Website Feedback Survey.docx Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction
Form CMS-10720 Final Overall Portal Feedback Survey (Spanish) Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction
Form CMS-10720 Final Overall Website Feedback Survey (Spanish).docx Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction
Form CMS-10720 Final Overall Portal Feedback Survey.docx Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction
CMS-10720 Overall Website Feedback Survey.docx CMS-10720.Final Overall Website Feedback Survey.docx	Form and Instruction
CMS-10720 Final Overall Portal Feedback Survey (Spanish) CMS-10720.Final Overall Portal Feedback Survey (Spanish).docx	Form and Instruction
CMS-10720 Final Overall Website Feedback Survey (Spanish).docx CMS-10720.Final Overall Website Feedback Survey (Spanish).docx	Form and Instruction
CMS-10720 Final Overall Portal Feedback Survey.docx CMS-10720.Final Overall Portal Feedback Survey.docx	Form and Instruction
CMS-10720.MAC Overall Site Experience Fast Track Request.docx CMS-10720.MAC Overall Site Experience Fast Track Request	IC Document

IC Title:

Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)

Agency IC Tracking Number:

IC Status: New

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-10720	Overall Website Feedback Survey.docx	CMS-10720.Final Overall Website Feedback Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10720	Final Overall Portal Feedback Survey (Spanish)	CMS-10720.Final Overall Portal Feedback Survey (Spanish).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10720	Final Overall Website Feedback Survey (Spanish).docx	CMS-10720.Final Overall Website Feedback Survey (Spanish).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10720	Final Overall Portal Feedback Survey.docx	CMS-10720.Final Overall Portal Feedback Survey.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35,000

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
Annual Number of Responses for this IC	35,000	35,000
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10720.MAC Overall Site Experience Fast Track Request	CMS-10720.MAC Overall Site Experience Fast Track Request.docx	11/22/2019

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