CAHPS for MIPS Survey Beneficiary Participation

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)

Documents and Forms

Document Name Document Type
Form CMS-10450 CAHPS for MIPS Survey Beneficiary Participation Form
Appendix-C1-2024-survey-initial-cover-letter.pdf Instruction
Appendix-C1-2024-survey-initial-cover-letter.pdf Instruction
Appendix-D1-2024-survey-second-cover-letter.pdf Instruction
Appendix-D1-2024-survey-second-cover-letter.pdf Instruction
CMS-10450 Mail Survey Appendix-B1-2024-mail-survey.pdf Form
CMS-10450 Mail Survey Appendix-B1-2024-mail-survey.pdf Form
CMS-10450 CAHPS for MIPS CATI Script Appendix-E1-2024-CATI-script.pdf Form and Instruction
CMS-10450 CAHPS for MIPS CATI Script Appendix-E1-2024-CATI-script.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	CAHPS for MIPS Survey Beneficiary Participation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.1330 and 414.1335

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10450	Mail Survey	Appendix-B1-2024-mail-survey.pdf	Yes	Yes	Fillable Fileable
Instruction			Appendix-C1-2024-survey-initial-cover-letter.pdf	Yes	Yes	Fillable Fileable
Instruction			Appendix-D1-2024-survey-second-cover-letter.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	CAHPS for MIPS CATI Script	Appendix-E1-2024-CATI-script.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25,500	-4,452	29,952
Annual IC Time Burden (Hours)	5,567	-973	6,540
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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