PaRIS Eligibility Screener

Patient-Reported Indicator Survey (PaRIS) (CMS-10792)

Documents and Forms

Document Name Document Type
Form CMS-10792 PaRIS Eligibility Screener Form and Instruction
CMS-10792 PaRIS Eligibility Screener Attachment 2. PaRIS Specifications.pdf Form and Instruction
Attach2_PaRIS_Showcards.pdf Showcards IC Document

Information Collection (IC) Details

IC Title:	PaRIS Eligibility Screener	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-10792	PaRIS Eligibility Screener	Attachment 2. PaRIS Specifications.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Current Beneficiary Survey (MCBS)	FR Citation: 83 FR 6591

Number of Respondents: 7,348	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,348	7,348
Annual IC Time Burden (Hours)	367	367
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Showcards	Attach2_PaRIS_Showcards.pdf	03/02/2022

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