Information Collection

Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)

IC 257111 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10729 Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	Form and Instruction
CMS-10729 Beneficiary Care Management Program Beneficiary Satisfac CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420.docx	Form and Instruction
CMS-10729 Beneficiary Care Management Program Beneficiary Satisfac CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420.docx	Form and Instruction
CMS-10729 BFCC-QIO TO4 Survey Questions Supporting Statement_041420.docx CMS-10729 BFCC-QIO TO4 Survey Questions Supporting Statement_041420	IC Document
CMS-10729 BFCC-QIO TO4 Survey Questions Supporting Statement_041420.docx CMS-10729 BFCC-QIO TO4 Survey Questions Supporting Statement_041420	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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-10729	Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420	CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10729 BFCC-QIO TO4 Survey Questions Supporting Statement_041420	CMS-10729 BFCC-QIO TO4 Survey Questions Supporting Statement_041420.docx	11/25/2022

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