Information Collection

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

IC 8171 under ICR 202004-0938-005 · OMB 0938-0568.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0568 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A) Form
CMS-P-0015A Cost Payment Summary 2019_Cost_Payment_Summary_CPS.pdf Form
CMS-P-0015A Demographic Income 2020_Demographics_and_Income_DIQ.pdf Form
CMS-P-0015A End Questionaire 2019_End_END.pdf Form
CMS-P-0015A Enumeration Summary 2019_Enumeration_Summary_ENS.pdf Form
CMS-P-0015A Home Health Summary 2018_Home_Health_Summary_HHS.pdf Form
CMS-P-0015A Interviewer Remarks 2019_Interviewer_Remarks_IRQ.pdf Form
CMS-P-0015A Mobility of Beneficiaries 2020_Mobility_of_Beneficiaries_MBQ.pdf Form
CMS-P-0015A Post Statement Cost 2019_Post_Statement_Cost_PSQ.pdf Form
CMS-P-0015A Access to Care 2020_Access_to_Care_ACQ.pdf Form
CMS-P-0015A Chronic Pain 2020_Chronic_Pain_CPQ.pdf Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2020_Dental_Vision_and_Hearing_Utilization_DVH.pdf Form
CMS-P-0015A Drug Coverage 2020_Drug_Coverage_RXQ.pdf Form
CMS-P-0015A Emergency Utilization 2019_Emergency_Utilization_ERQ.pdf Form
CMS-P-0015A Health Insurance 2020_Health_Insurance_HIQ.pdf Form
CMS-P-0015A Home Health 2020_Home_Health_Utilization_HHQ.pdf Form
CMS-P-0015A Housing_Characteristics 2019_Housing_Charcs_HAQ.pdf Form
CMS-P-0015A Income_and_ Assets 2019_Income_and_ Assets_IAQ.pdf Form
CMS-P-0015A Inpatient Utilization 2019_Inpatient_Utilization_IPQ.pdf Form
CMS-P-0015A Institutional Utilization 2020_Institutional_Utilization_IUQ.pdf Form
CMS-P-0015A Introduction 2020_Introduction_INQ.pdf Form
CMS-P-0015A Medical Provider Utilzation 2020_Medical_Provider_Utilization_MPQ.pdf Form
CMS-P-0015A Nicotine Alcohol 2019_Nicotine_Alcohol_Use_NAQ.pdf Form
CMS-P-0015A No Statement Cost 2020_No_Statement_Cost_Series_NSQ.pdf Form
CMS-P-0015A Other Medical Expense 2019_Other_Medical_Expenses_OMQ.pdf Form
CMS-P-0015A Outpatient Utilization 2019_Outpatient_Util_OPQ.pdf Form
CMS-P-0015A Prescribed Medicine Utilization 2020_Prescribed_Medicine_Utilization_PMQ.pdf Form
CMS-P-0015A Satisfaction Care 2020_Satisfaction_with_Care_SCQ.pdf Form
CMS-P-0015A Statement Cost Series 2020_Statement_Cost_Series_STQ.pdf Form
CMS-P-0015A Beneficiary Knowledge 2021_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf Form
CMS-P-0015A Preventive Care 2020_Preventive_Care_PVQ.pdf Form
CMS-P-0015A Usual Source of Care 2020_Usual_Source_Of_Care_USQ.pdf Form
CMS-P-0015A Showcards and Reference Cards 2021CommShowcards.pdf Form
CMS-P-0015A Facility Showcards 2018FacilityShowcards508.pdf Form
CMS-P-0015A Facility Screener Attachment 4 Fac2019_Fac_Screener_FACSCREEN.pdf Form
CMS-P-0015A Residence History Missing Data Fac2019_Residence_Missing_RHM.pdf Form
CMS-P-0015A Residence History Fac2019_Residence_History_RH.pdf Form
CMS-P-0015A Use of Health Services Fac2019_Use_Health_Services_US.pdf Form
CMS-P-0015A Background_Questionnaire Fac2019_Background_BQ.pdf Form
CMS-P-0015A Background_Questionnaire MIssing Data Fac2019_Background_Missing_BQM.pdf Form
CMS-P-0015A Expenditures Fac2019_Expenditures_EX.pdf Form
CMS-P-0015A Questionaire Missing Data Fac2020_Facility_Missing_FQM.pdf Form
CMS-P-0015A Questionaire Fac2020_Facility_Quex_FQ.pdf Form
CMS-P-0015A Health_Insurance Fac2019_Health_Insurance_IN.pdf Form
CMS-P-0015A Health_Status Fac2019_Health_Status_HS.pdf Form
CMS-P-0015A Health Status Attachment A - R88 HFQ.PDF Form
CMS-P-0015A Cognitive_Measure 2020_Cognitive_Measures_CMQ.pdf Form
CMS-P-0015A Health_Status_and_Functioning_ 2021_Health_Status_and_Functioning_HFQ.pdf Form
CMS-P-0015A Physical_Measures 2021_Physical_Measures_PXQ.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Agency IC Tracking Number:	CM-CPC

Is this a Common Form? No		IC Status: Modified

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	CMS-P-0015A	Facility Screener	Attachment 4 Fac2019_Fac_Screener_FACSCREEN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History Missing Data	Fac2019_Residence_Missing_RHM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History	Fac2019_Residence_History_RH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Use of Health Services	Fac2019_Use_Health_Services_US.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire	Fac2019_Background_BQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire MIssing Data	Fac2019_Background_Missing_BQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Expenditures	Fac2019_Expenditures_EX.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire Missing Data	Fac2020_Facility_Missing_FQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire	Fac2020_Facility_Quex_FQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Insurance	Fac2019_Health_Insurance_IN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Status	Fac2019_Health_Status_HS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health Status	Attachment A - R88 HFQ.PDF	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Cognitive_Measure	2020_Cognitive_Measures_CMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Status_and_Functioning_	2021_Health_Status_and_Functioning_HFQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Physical_Measures	2021_Physical_Measures_PXQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Cost Payment Summary	2019_Cost_Payment_Summary_CPS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Demographic Income	2020_Demographics_and_Income_DIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	End Questionaire	2019_End_END.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Enumeration Summary	2019_Enumeration_Summary_ENS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Home Health Summary	2018_Home_Health_Summary_HHS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Interviewer Remarks	2019_Interviewer_Remarks_IRQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Mobility of Beneficiaries	2020_Mobility_of_Beneficiaries_MBQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Post Statement Cost	2019_Post_Statement_Cost_PSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Access to Care	2020_Access_to_Care_ACQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Chronic Pain	2020_Chronic_Pain_CPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Dental, Vision, and Hearing Care Utilization	2020_Dental_Vision_and_Hearing_Utilization_DVH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Drug Coverage	2020_Drug_Coverage_RXQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Emergency Utilization	2019_Emergency_Utilization_ERQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health Insurance	2020_Health_Insurance_HIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Home Health	2020_Home_Health_Utilization_HHQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Housing_Characteristics	2019_Housing_Charcs_HAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Income_and_ Assets	2019_Income_and_ Assets_IAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Inpatient Utilization	2019_Inpatient_Utilization_IPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Institutional Utilization	2020_Institutional_Utilization_IUQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Introduction	2020_Introduction_INQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Medical Provider Utilzation	2020_Medical_Provider_Utilization_MPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Nicotine Alcohol	2019_Nicotine_Alcohol_Use_NAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	No Statement Cost	2020_No_Statement_Cost_Series_NSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Other Medical Expense	2019_Other_Medical_Expenses_OMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Outpatient Utilization	2019_Outpatient_Util_OPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Prescribed Medicine Utilization	2020_Prescribed_Medicine_Utilization_PMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Satisfaction Care	2020_Satisfaction_with_Care_SCQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Statement Cost Series	2020_Statement_Cost_Series_STQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Beneficiary Knowledge	2021_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Preventive Care	2020_Preventive_Care_PVQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Usual Source of Care	2020_Usual_Source_Of_Care_USQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Showcards and Reference Cards	2021CommShowcards.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Facility Showcards	2018FacilityShowcards508.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35,998	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	35,998	0	35,998
Annual IC Time Burden (Hours)	44,573	1,963	42,610
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.