OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)

IC 257108 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10721
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)		 Form and Instruction
CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey
CMS-10721.Final Persistent Portal Feedback Survey.docx 		Form and Instruction
CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey
CMS-10721.Final Persistent Portal Feedback Survey.docx 		Form and Instruction
CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey (Spani
CMS-10721.Final Persistent Portal Feedback Survey (Spanish).docx 		Form and Instruction
CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey (Spani
CMS-10721.Final Persistent Portal Feedback Survey (Spanish).docx 		Form and Instruction
CMS-10721 CMS-10721.Final Persistent Website Feedback Survey
CMS-10721.Final Persistent Website Feedback Survey.docx 		Form and Instruction
CMS-10721 CMS-10721.Final Persistent Website Feedback Survey
CMS-10721.Final Persistent Website Feedback Survey.docx 		Form and Instruction
CMS-10721 CMS-10721.Final Persistent Website Feedback Survey (Span
CMS-10721.Final Persistent Website Feedback Survey (Spanish).docx 		Form and Instruction
CMS-10721 CMS-10721.Final Persistent Website Feedback Survey (Span
CMS-10721.Final Persistent Website Feedback Survey (Spanish).docx 		Form and Instruction
CMS-10721.MAC Persistent Feedback Fast Track Request.docx
CMS-10721.MAC Persistent Feedback Fast Track Request		IC Document
CMS-10721.MAC Persistent Feedback Fast Track Request.docx
CMS-10721.MAC Persistent Feedback Fast Track Request		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey CMS-10721.Final Persistent Portal Feedback Survey.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey (Spanish) CMS-10721.Final Persistent Portal Feedback Survey (Spanish).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10721 CMS-10721.Final Persistent Website Feedback Survey CMS-10721.Final Persistent Website Feedback Survey.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10721 CMS-10721.Final Persistent Website Feedback Survey (Spanish) CMS-10721.Final Persistent Website Feedback Survey (Spanish).docx Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 45,000 0 45,000 0 0 0
Annual IC Time Burden (Hours) 750 0 750 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
CMS-10721.MAC Persistent Feedback Fast Track Request CMS-10721.MAC Persistent Feedback Fast Track Request.docx 11/25/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.