Information Collection

Medicare Beneficiary and Family-Centered Satisfaction Survey

IC 201543 under ICR 202310-0938-005 · OMB 0938-1177.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1177 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey	Form and Instruction
CMS-10393 Attachment B: Beneficiary Experience Survey CMS-10393_Attachment B_Experience Survey_06.29.2023.docx	Form and Instruction
CMS-10393 Attachment B: Beneficiary Experience Survey CMS-10393_Attachment B_Experience Survey_06.29.2023.docx	Form and Instruction
CMS-10393_Attachment A_Related Legislation_06.29.2023_508.pdf Legislation	IC Document
CMS-10393_Attachment A_Related Legislation_06.29.2023_508.pdf Legislation	IC Document

IC Title:

Medicare Beneficiary and Family-Centered Satisfaction Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10393	Attachment B: Beneficiary Experience Survey	CMS-10393_Attachment B_Experience Survey_06.29.2023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	9,000	300	8,700
Annual IC Time Burden (Hours)	2,250	75	2,175
Annual IC Cost Burden (Dollars)	31,365	1,045	30,320

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Legislation	CMS-10393_Attachment A_Related Legislation_06.29.2023_508.pdf	10/27/2023

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