Medicare Beneficiary and Family-Centered Satisfaction Survey

Beneficiary and Family Centered Data Collection (CMS-10393)

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.