Information Collection

Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761)

IC 257118 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10761 Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761)	Form and Instruction
CMS-10761 Final Overall Mobile Feedback Survey-final CMS-10761.Final Overall Mobile Feedback Survey-final.docx	Form and Instruction
CMS-10761 Final Overall Mobile Feedback Survey-final CMS-10761.Final Overall Mobile Feedback Survey-final.docx	Form and Instruction
CMS-10761 Final Overall Mobil Application Feedback Survey (Spanish CMS-1761.Final Overall Mobil Application Feedback Survey (Spanish)-final (1).docx	Form and Instruction
CMS-10761 Final Overall Mobil Application Feedback Survey (Spanish CMS-1761.Final Overall Mobil Application Feedback Survey (Spanish)-final (1).docx	Form and Instruction
CMS-10761.MAC Overall Mobile Site Experience Fast Track (2).docx CMS-10761.MAC Overall Mobile Site Experience Fast Track Request	IC Document
CMS-10761.MAC Overall Mobile Site Experience Fast Track (2).docx CMS-10761.MAC Overall Mobile Site Experience Fast Track Request	IC Document

IC Title:

Medicare Administrative Contractor (MAC) Provider Customer Experience â Mobile Application (CMS-10761)

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-10761	Final Overall Mobile Feedback Survey-final	CMS-10761.Final Overall Mobile Feedback Survey-final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10761	Final Overall Mobil Application Feedback Survey (Spanish)-final (1)	CMS-1761.Final Overall Mobil Application Feedback Survey (Spanish)-final (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10761.MAC Overall Mobile Site Experience Fast Track Request	CMS-10761.MAC Overall Mobile Site Experience Fast Track (2).docx	11/25/2022

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