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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	Agency IC Tracking Number:

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-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 %

	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

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.