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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10720 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

Information Collection (IC) Details

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:

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 %

	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

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.