Information Collection

HOPDs/ASCs Patient Records

IC 216391 under ICR 202402-0938-009 · OMB 0938-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

2026-02-19 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 HOPDs/ASCs Patient Records	Form and Instruction
Form CMS-10500 OAS CAHPS (Mail Survey) HOPDs/ASCs Patient Records	Form and Instruction
Form CMS-10500 OAS CAHPS (Telephone Script) HOPDs/ASCs Patient Records	Form
Form CMS-10500 OAS CAHPS (Web Survey Screenshots) HOPDs/ASCs Patient Records	Form and Instruction
Form CMS-10500 OAS CAHPS - Spanish HOPDs/ASCs Patient Records	Form and Instruction
Form CMS-10500 OAS CAHPS - ChineseSimplified. HOPDs/ASCs Patient Records	Form and Instruction
Form CMS-10500 OAS CAHPS - ChineseTraditional HOPDs/ASCs Patient Records	Form and Instruction
Form CMS-10500 OAS CAHPS - Korean HOPDs/ASCs Patient Records	Form and Instruction
Form CMS-10500 OAS CAHPS - Russian HOPDs/ASCs Patient Records	Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) OAS CAHPS Attachment A-Mail Questionnaire.pdf	Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) OAS CAHPS Attachment A-Mail Questionnaire.pdf	Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) OAS CAHPS Attachment B-CATI Questionnaire.pdf	Form
CMS-10500 OAS CAHPS (Telephone Script) OAS CAHPS Attachment B-CATI Questionnaire.pdf	Form
CMS-10500 OAS CAHPS (Web Survey Screenshots) OAS CAHPS Attachment C-Web Questionnaire.pdf	Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) OAS CAHPS Attachment C-Web Questionnaire.pdf	Form and Instruction
CMS-10500 OAS CAHPS - Spanish Attachment E1 - OAS CAHPS - Spanish Survey.pdf	Form and Instruction
CMS-10500 OAS CAHPS - Spanish Attachment E1 - OAS CAHPS - Spanish Survey.pdf	Form and Instruction
CMS-10500 OAS CAHPS - ChineseSimplified. Attachment E2 - OAS CAHPS - ChineseSimplified.pdf	Form and Instruction
CMS-10500 OAS CAHPS - ChineseSimplified. Attachment E2 - OAS CAHPS - ChineseSimplified.pdf	Form and Instruction
CMS-10500 OAS CAHPS - ChineseTraditional Attachment E3 - OAS CAHPS - ChineseTraditional.pdf	Form and Instruction
CMS-10500 OAS CAHPS - ChineseTraditional Attachment E3 - OAS CAHPS - ChineseTraditional.pdf	Form and Instruction
CMS-10500 OAS CAHPS - Korean Attachment E4 - OAS CAHPS - Korean.pdf	Form and Instruction
CMS-10500 OAS CAHPS - Korean Attachment E4 - OAS CAHPS - Korean.pdf	Form and Instruction
CMS-10500 OAS CAHPS - Russian Attachment E5 - OAS CAHPS - Russian.pdf	Form and Instruction
CMS-10500 OAS CAHPS - Russian Attachment E5 - OAS CAHPS - Russian.pdf	Form and Instruction
OAS CAHPS Attachment D1-Mail Cover Letters.pdf Cover Letters	IC Document
OAS CAHPS Attachment D1-Mail Cover Letters.pdf Cover Letters	IC Document
OAS CAHPS Attachment D2-Initial Web Survey Invitation Letter.pdf Letter Invitation for Web Survey	IC Document
OAS CAHPS Attachment D2-Initial Web Survey Invitation Letter.pdf Letter Invitation for Web Survey	IC Document
OAS CAHPS Attachment D3-Initial Web Survey Invitation Email.pdf E-mail Invitation for Web Survey (1st Contact)	IC Document
OAS CAHPS Attachment D3-Initial Web Survey Invitation Email.pdf E-mail Invitation for Web Survey (1st Contact)	IC Document
OAS CAHPS Attachment D4-Followup Web Survey Invitation Letter.pdf Followup Web Survey Invitation Letter	IC Document
OAS CAHPS Attachment D4-Followup Web Survey Invitation Letter.pdf Followup Web Survey Invitation Letter	IC Document
OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf Follow up Web Survey Invitation Email	IC Document
OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf Follow up Web Survey Invitation Email	IC Document
OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf Web with Mail Followup_Questionnaire Cover Letter	IC Document
OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf Web with Mail Followup_Questionnaire Cover Letter	IC Document
OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf Prenote Letter for Telephone Only	IC Document
OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf Prenote Letter for Telephone Only	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

HOPDs/ASCs Patient Records

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10500	No		Fillable Fileable
Form	CMS-10500	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,243

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,243	6,943	3,300
Annual IC Time Burden (Hours)	286,804	194,404	92,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letters		02/23/2024
Letter Invitation for Web Survey		02/23/2024
E-mail Invitation for Web Survey (1st Contact)		02/23/2024
Followup Web Survey Invitation Letter		02/23/2024
Follow up Web Survey Invitation Email		02/23/2024
Web with Mail Followup_Questionnaire Cover Letter		02/23/2024
Prenote Letter for Telephone Only		02/23/2024

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

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