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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10762 Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)	Form and Instruction
CMS-10762 Final Persistent Mobile Feedback Survey CMS-10762.Final Persistent MobileFeedback Survey - final.docx	Form and Instruction
CMS-10762 Final Persistent Mobile Feedback Survey CMS-10762.Final Persistent MobileFeedback Survey - final.docx	Form and Instruction
CMS-10762 CMS-10762.Final Persistent Mobil Application Feedback Su CMS-10762.Final Persistent Mobil Application Feedback Survey (Spanish).docx	Form and Instruction
CMS-10762 CMS-10762.Final Persistent Mobil Application Feedback Su CMS-10762.Final Persistent Mobil Application Feedback Survey (Spanish).docx	Form and Instruction
CMS-10762.MAC Mobile Persistent Feedback Fast Track.docx CMS-10762.MAC Mobile Persistent Feedback Fast Track Request	IC Document
CMS-10762.MAC Mobile Persistent Feedback Fast Track.docx CMS-10762.MAC Mobile Persistent Feedback Fast Track Request	IC Document

IC Title:

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

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-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

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: Private Sector

Private Sector: Businesses or other for-profits

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)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.