Information Collection

Medicare Beneficiary Experiences with Care Survey (MBECS) System

IC 239103 under ICR 201912-0938-022 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10701 Medicare Beneficiary Experiences with Care Survey (MBECS) System	Form and Instruction
CMS-10701 (MBECS)Core Questionnaire Attachment A - MBECS questionnaire.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

OMH

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10701	(MBECS)Core Questionnaire	Attachment A - MBECS questionnaire.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	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.