CMS-10450 Mail Survey

CAHPS® Survey for Merit-based Incentive Payment
System (MIPS)
2024 Survey
Note: The final version of the CAHPS for MIPS survey will be posted
to the QPP website.

Medicare Provider Experience Survey
Survey Instructions
This survey asks about you and the health care you received in the last six months during visits that
were in-person, by phone or by video call. Answer each question thinking about yourself. Please take
the time to complete this survey. Your answers are very important to us. Please return the survey with
your answers in the enclosed postage-paid envelope to [VENDOR NAME].
Answer all the questions by putting an “X” in the box to the left of your answer, like this:

 Yes
Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. When this happens you will see
an arrow with a note that tells you what question to answer next, like this:
[➔ If No, go to #3]. See the example below:
EXAMPLE
1. Do you wear a hearing aid now?
☐ Yes
 No ➔ If No, go to #3

3. In the last 6 months, did you have any
headaches?
 Yes
☐ No

2. How long have you been wearing a hearing
aid?
☐ Less than one year
☐ 1 to 3 years
☐ More than 3 years
☐ I don’t wear a hearing aid
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381222 (Expiration date: 3/31/2027). The time required to complete this information collection is estimated to average 13.1
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under
the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions
or concerns regarding where to submit your documents, please contact [email protected].

Centers for Medicare & Medicaid Services

1

Your Provider
1. Our records show that you visited the
provider named below in the last 6 months.
Name of provider label goes here

Your Care From This Provider in the
Last 6 Months
These questions ask about your own health
care. Do not include care you got when you
stayed overnight in a hospital. Do not include
the times you went for dental care visits.

Is that right?
 Yes
 No ➔If No, go to #24
The questions in this survey will refer to the
provider named in Question 1 as “this provider.”
Please think of that person as you answer the
survey.
2. Is this the provider you usually see if you
need a check-up, want advice about a health
problem, or get sick or hurt?
 Yes
 No
3. How long have you been going to this
provider?






Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more

4. In the last 6 months, how many times did
you visit this provider to get care for
yourself?








5. In the last 6 months, did you contact this
provider’s office to get an appointment for
an illness, injury or condition that needed
care right away?
 Yes
 No ➔If No, go to #7
6. In the last 6 months, when you contacted
this provider’s office to get an appointment
for care you needed right away, how often
did you get an appointment as soon as you
needed?





2

None ➔If None, go to #24
1 time
2
3
4
5 to 9
10 or more times

Never
Sometimes
Usually
Always

Centers for Medicare & Medicaid Services

7. In the last 6 months, did you make any
appointments for a check-up or routine
care with this provider?

12.






 Yes
 No ➔If No, go to #9
8. In the last 6 months, when you made an
appointment for a check-up or routine
care with this provider, how often did you
get an appointment as soon as you needed?





13.

Never
Sometimes
Usually
Always

9. In the last 6 months, did you contact this
provider’s office with a medical question
during regular office hours?

14.

Never
Sometimes
Usually
Always

15.






16.
Never
Sometimes
Usually
Always

Centers for Medicare & Medicaid Services

Never
Sometimes
Usually
Always

In the last 6 months, how often did this
provider spend enough time with you?





11. In the last 6 months, how often did this
provider explain things in a way that was
easy to understand?

Never
Sometimes
Usually
Always

In the last 6 months, how often did this
provider show respect for what you had to
say?





10. In the last 6 months, when you contacted
this provider’s office during regular office
hours, how often did you get an answer to
your medical question that same day?

Never
Sometimes
Usually
Always

In the last 6 months, how often did
this provider seem to know the
important information about your
medical history?





 Yes
 No ➔If No, go to #11






In the last 6 months, how often did this
provider listen carefully to you?

Never
Sometimes
Usually
Always

In the last 6 months, did this provider
order a blood test, x-ray, or other test for
you?
 Yes
 No ➔If No, go to #18

3

17. In the last 6 months, when this provider
ordered a blood test, x-ray, or other test for
you, how often did someone from this
provider’s office follow up to give you those
results?





Clerks and Receptionists at This
Provider’s Office
22.

Never
Sometimes
Usually
Always

18. In the last 6 months, did you and this
provider talk about starting or stopping a
prescription medicine?





23.

 Yes
 No ➔If No, go to #20
19. When you and this provider talked about
starting or stopping a prescription
medicine, did this provider ask what you
thought was best for you?
 Yes
 No

4

0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible

Never
Sometimes
Usually
Always

Your Care From Specialists in the
Last 6 Months
24.

 Yes
 No













Never
Sometimes
Usually
Always

In the last 6 months, how often did clerks
and receptionists at this provider’s office
treat you with courtesy and respect?





20. In the last 6 months, did you and this
provider talk about how much of your
personal health information you wanted
shared with your family or friends?

21. Using any number from 0 to 10, where 0 is
the worst provider possible and 10 is the
best provider possible, what number would
you use to rate this provider?

In the last 6 months, how often were clerks
and receptionists at this provider’s office
as helpful as you thought they should be?

Specialists are doctors like surgeons,
heart doctors, allergy doctors, skin
doctors, and other doctors who specialize
in one area of health care. Is the
provider named in Question 1 of this
survey a specialist?
 Yes➔If Yes, Please include this
provider as you answer these
questions about specialists

 No
25.

In the last 6 months, did you try to make
any appointments with specialists?
 Yes
 No ➔If No, go to #27

Centers for Medicare & Medicaid Services

26. In the last 6 months, how often was it easy
to get appointments with specialists?





Never
Sometimes
Usually
Always

31.

 Yes
 No
32.

All Your Care in the Last 6 Months
These questions ask about all your health
care. Include all the providers you saw for
health care in the last 6 months. Do not
include the times you went for dental care
visits.

33.

About You
34.

35.

 Yes
 No ➔If No, go to #32

Centers for Medicare & Medicaid Services

36.

Excellent
Very good
Good
Fair
Poor

In general, how would you rate your
overall mental or emotional health?






30. In the last 6 months, how often did you
and anyone on your health care team
talk about all the prescription medicines
you were taking?
Never
Sometimes
Usually
Always

In general, how would you rate your
overall health?






 Yes
 No






In the last 6 months, did you and anyone
on your health care team talk about things
in your life that worry you or cause you
stress?
 Yes
 No

28. In the last 6 months, did you and anyone
on your health care team talk about the
exercise or physical activity you get?

29. In the last 6 months, did you take any
prescription medicine?

In the last 6 months, did anyone on your
health care team ask you if there was a
period of time when you felt sad, empty,
or depressed?
 Yes
 No

27. Your health care team includes all the
doctors, nurses and other people you see
for health care. In the last 6 months, did
you and anyone on your health care team
talk about a healthy diet and healthy eating
habits?
 Yes
 No

In the last 6 months, did you and anyone
on your health care team talk about how
much your prescription medicines cost?

Excellent
Very good
Good
Fair
Poor

In the last 12 months, have you seen a
doctor or other health provider 3 or more
times for the same condition or problem?
 Yes
 No ➔If No, go to #38
5

37.

Is this a condition or problem that has
lasted for at least 3 months?

42.












 Yes
 No
38.

Do you now need or take medicine
prescribed by a doctor?
 Yes
 No ➔If No, go to #40

39.

Is this medicine to treat a condition that
has lasted for at least 3 months?

43.

 Yes
 No

41.

All of the time
Most of the time
Some of the time
A little of the time
None of the time

44.

Are you male or female?

What is the highest grade or level of
school that you have completed?







No
⃞
⃞
⃞

During the last 4 weeks, how much of the
time did your physical health interfere
with your social activities (like visiting
with friends, relatives, etc.)?






18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 or older

 Male
 Female

40. In the last 6 months, were any of your
visits for your own health care…
Yes
a. In person? ........................⃞
b. By phone? .......................⃞
c. By video call?..................⃞

What is your age?

45.

How well do you speak English?





46.

8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

Very well
Well
Not well
Not at all

Do you speak a language other than
English at home?
 Yes
 No ➔If No, go to #48

6

Centers for Medicare & Medicaid Services

47. What is the language you speak at home?







Spanish
Chinese
Korean
Russian
Vietnamese
Some other language

53. Because of a physical, mental, or emotional
condition, do you have difficulty doing
errands alone such as visiting a doctor’s
office or shopping?
 Yes
 No
54. Do you ever use the internet at home?

48. Are you deaf or do you have serious
difficulty hearing?
 Yes
 No
49. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
 Yes
 No
50. Because of a physical, mental, or
emotional condition, do you have serious
difficulty concentrating, remembering, or
making decisions?
 Yes
 No

 Yes
 No
55. Are you of Hispanic, Latino, or Spanish
origin?
 Yes, Hispanic, Latino, or Spanish
 No, not Hispanic, Latino, or Spanish
➔If No, go to #57
56. Which group best describes you?
 Mexican, Mexican American, Chicano
➔Go to #57
 Puerto Rican ➔Go to #57
 Cuban ➔Go to #57
 Another Hispanic, Latino, or Spanish
origin ➔Go to #57

51. Do you have serious difficulty walking or
climbing stairs?
 Yes
 No
52. Do you have difficulty dressing or bathing?
 Yes
 No

Centers for Medicare & Medicaid Services

7

57.

What is your race? Mark one or more.















American Indian or Alaska Native
Black or African American
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Guamanian or Chamorro
Native Hawaiian
Samoan
Other Pacific Islander
White

58.

Did someone help you complete this
survey?
 Yes
 No ➔Thank you.
Please return the completed
survey in the postage-paid
envelope.

59.

How did that person help you? Mark
one or more.





Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
 Helped in some other way

Thank you
Please return the completed survey in the postage-paid envelope.
[VENDOR NAME AND ADDRESS HERE]

8

Centers for Medicare & Medicaid Services