Information Collection

CAHPS for MIPS Survey Beneficiary Participation

IC 206234 under ICR 202107-0938-012 · OMB 0938-1222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10450 CAHPS for MIPS Survey Beneficiary Participation	Form
Appendix B1 2021_survey_initial_cover_letter_english_clean.pdf	Instruction
Appendix C1 2021_survey_second_cover_letter_english_clean.pdf	Instruction
CMS-10450 Mail Survey Appendix A1 2021_mail_survey.pdf	Form
CMS-10450 CAHPS for MIPS CATI Script Appendix D1 2021_CAHPS_for_MIPS_CATI_Script (1).pdf	Form and Instruction
Appendix A2 Mail Survey Crosswalk .pdf Mail Survey Crosswalk	IC Document
Appendix B2 2021_Survey Initial Cover Letter Crosswalk 2020-12-29 .pdf Suvey Initial Letter Crosswalk	IC Document
Appendix C2 Survey Second Cover Letter Crosswalk 2020-12-29 .pdf Survey Second Letter Crosswalk	IC Document
Appendix D2 CAHPS for MIPS CATI Script Crosswalk.pdf CAHPS for MIPS CATI Script Crosswalk	IC Document

IC Title:

CAHPS for MIPS Survey Beneficiary Participation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.1330 and 414.1335

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	CMS-10450	Mail Survey	Appendix A1 2021_mail_survey.pdf	Yes	Yes	Fillable Fileable
Instruction			Appendix B1 2021_survey_initial_cover_letter_english_clean.pdf	Yes	Yes	Fillable Fileable
Instruction			Appendix C1 2021_survey_second_cover_letter_english_clean.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	CAHPS for MIPS CATI Script	Appendix D1 2021_CAHPS_for_MIPS_CATI_Script (1).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 29,952

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	Previously Approved
Annual Number of Responses for this IC	29,952	29,952
Annual IC Time Burden (Hours)	6,540	6,540
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mail Survey Crosswalk	Appendix A2 Mail Survey Crosswalk .pdf	02/26/2021
Suvey Initial Letter Crosswalk	Appendix B2 2021_Survey Initial Cover Letter Crosswalk 2020-12-29 .pdf	02/26/2021
Survey Second Letter Crosswalk	Appendix C2 Survey Second Cover Letter Crosswalk 2020-12-29 .pdf	02/26/2021
CAHPS for MIPS CATI Script Crosswalk	Appendix D2 CAHPS for MIPS CATI Script Crosswalk.pdf	02/26/2021

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