Information Collection

HOPDs/ASCs Patient Records

IC 216391 under ICR 202107-0938-015 · OMB 0938-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 HOPDs/ASCs Patient Records	Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) OAS CAHPS Attachment A-Mail Questionnaire.pdf	Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) OAS CAHPS Attachment A-Mail Questionnaire.pdf	Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) OAS CAHPS Attachment B-CATI Questionnaire.pdf	Form
CMS-10500 OAS CAHPS (Telephone Script) OAS CAHPS Attachment B-CATI Questionnaire.pdf	Form
CMS-10500 OAS CAHPS (Web Survey Screenshots) OAS CAHPS Attachment C-Web Questionnaire.pdf	Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) OAS CAHPS Attachment C-Web Questionnaire.pdf	Form and Instruction
OAS CAHPS Attachment D1-Mail Cover Letters.pdf Cover Letters	IC Document
OAS CAHPS Attachment D1-Mail Cover Letters.pdf Cover Letters	IC Document
OAS CAHPS Attachment D2-Initial Web Survey Invitation Letter.pdf Letter Invitation for Web Survey	IC Document
OAS CAHPS Attachment D2-Initial Web Survey Invitation Letter.pdf Letter Invitation for Web Survey	IC Document
OAS CAHPS Attachment D3-Initial Web Survey Invitation Email.pdf E-mail Invitation for Web Survey (1st Contact)	IC Document
OAS CAHPS Attachment D3-Initial Web Survey Invitation Email.pdf E-mail Invitation for Web Survey (1st Contact)	IC Document
OAS CAHPS Attachment D4-Followup Web Survey Invitation Letter.pdf Followup Web Survey Invitation Letter	IC Document
OAS CAHPS Attachment D4-Followup Web Survey Invitation Letter.pdf Followup Web Survey Invitation Letter	IC Document
OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf Follow up Web Survey Invitation Email	IC Document
OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf Follow up Web Survey Invitation Email	IC Document
OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf Web with Mail Followup_Questionnaire Cover Letter	IC Document
OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf Web with Mail Followup_Questionnaire Cover Letter	IC Document
OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf Prenote Letter for Telephone Only	IC Document
OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf Prenote Letter for Telephone Only	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

HOPDs/ASCs Patient Records

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	CMS-10500	OAS CAHPS (Mail Survey)	OAS CAHPS Attachment A-Mail Questionnaire.pdf	No		Fillable Fileable
Form	CMS-10500	OAS CAHPS (Telephone Script)	OAS CAHPS Attachment B-CATI Questionnaire.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Web Survey Screenshots)	OAS CAHPS Attachment C-Web Questionnaire.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: 3,300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,300	1,126	2,174
Annual IC Time Burden (Hours)	92,400	20,269	72,131
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letters	OAS CAHPS Attachment D1-Mail Cover Letters.pdf	07/26/2021
Letter Invitation for Web Survey	OAS CAHPS Attachment D2-Initial Web Survey Invitation Letter.pdf	07/26/2021
E-mail Invitation for Web Survey (1st Contact)	OAS CAHPS Attachment D3-Initial Web Survey Invitation Email.pdf	07/26/2021
Followup Web Survey Invitation Letter	OAS CAHPS Attachment D4-Followup Web Survey Invitation Letter.pdf	07/26/2021
Follow up Web Survey Invitation Email	OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf	07/26/2021
Web with Mail Followup_Questionnaire Cover Letter	OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf	07/26/2021
Prenote Letter for Telephone Only	OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf	07/26/2021

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