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Federal forms, ICRs, and supporting documents

Information Collection

Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)

IC 257120 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

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Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10762 Final Persistent Mobile Feedback Survey CMS-10762.Final Persistent MobileFeedback Survey - final.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10762 CMS-10762.Final Persistent Mobil Application Feedback Survey (Spanish) CMS-10762.Final Persistent Mobil Application Feedback Survey (Spanish).docx Yes Yes Fillable Fileable

Health Health Care Services

 

500 0
   
Private Sector Businesses or other for-profits
 
   100 %

  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 500 0 500 0 0 0
Annual IC Time Burden (Hours) 8 0 8 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10762.MAC Mobile Persistent Feedback Fast Track Request CMS-10762.MAC Mobile Persistent Feedback Fast Track.docx 11/25/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.