Part A Providers Web-Based Survey

QIC Demonstration Evaluation Contractor (QDEC): Analyze Medicare Appeals to Conduct Formal Discussions and Reopenings with DME Suppliers and Part A Providers (CMS-10633)

Documents and Forms

Document Name Document Type
Form CMS-10633 Part A Providers Web-Based Survey Form and Instruction
CMS-10633 Web Based Surveys QDEC-Attachment A-WebBasedSurvey_508compliant.pdf Form and Instruction
CMS-10633 Part A Survey Screenshots QDEC_Attachment E Part A survey screenshots.pdf Form
QDEC_Attachment A Web Based Survey_508 Compliant.pdf IC Document

Information Collection (IC) Details

IC Title:	Part A Providers Web-Based Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10633	Web Based Surveys	QDEC-Attachment A-WebBasedSurvey_508compliant.pdf		Yes	Yes	Fillable Fileable
Form	CMS-10633	Part A Survey Screenshots	QDEC_Attachment E Part A survey screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,544	Number of Respondents for Small Entity: 1,524

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,544	2,544
Annual IC Time Burden (Hours)	425	425
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
	QDEC_Attachment A Web Based Survey_508 Compliant.pdf	06/27/2017

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