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Federal forms, ICRs, and supporting documents

Information Collection

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

IC 8171 under ICR 202504-0938-006 · OMB 0938-0568.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-P-0015A
Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Cost Payment Summary Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Demographic Income Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
End Questionaire Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Enumeration Summary Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Mobility of Beneficiaries Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Post Statement Cost Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Access to Care Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Chronic Pain Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Dental, Vision, and Hearing Care Utilization Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Drug Coverage Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Emergency Utilization Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Health Insurance Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Home Health Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Housing_Characteristics Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Income_and_ Assets Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Inpatient Utilization Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Institutional Utilization Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Introduction Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Medical Provider Utilzation Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Nicotine Alcohol Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
No Statement Cost Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Other Medical Expense Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Outpatient Utilization Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Prescribed Medicine Utilization Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Satisfaction Care Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Statement Cost Series Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Beneficiary Knowledge Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Preventive Care Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Usual Source of Care Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Showcards and Reference Cards Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Facility Showcards Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Facility Screener Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Residence History Missing Data Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Residence History Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Use of Health Services Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Background_Questionnaire Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Background_Questionnaire MIssing Data Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Expenditures Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Questionaire Missing Data Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Questionaire Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Health_Insurance Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Health_Status Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Cognitive Measures Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
HFQ - Health Status and Functioning Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Physical_Measures Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form P-0015A
COVID-19 Questionnaire Specifications Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form P-0015A
COVID-19 Facility-Level Supplement Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Use of Health Services Section Specifications Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Telemedicine Questionnaire Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Physical Measures Frequently Asked Questions (FAQ) Sheet Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Immunization Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Health_Status Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
Form CMS-P-0015A
Interviewer_Remarks Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)		 Form
CMS-P-0015A Cost Payment Summary
2024_Cost_Payment_Summary_CPS.pdf 		Form
CMS-P-0015A Cost Payment Summary
2024_Cost_Payment_Summary_CPS.pdf 		Form
CMS-P-0015A Demographic Income
2025_Demographics_Income_DIQ.pdf 		Form
CMS-P-0015A Demographic Income
2025_Demographics_Income_DIQ.pdf 		Form
CMS-P-0015A End Questionaire
2023_End_END.pdf 		Form
CMS-P-0015A End Questionaire
2023_End_END.pdf 		Form
CMS-P-0015A Enumeration Summary
2023_Enumeration_Summary_ENS.pdf 		Form
CMS-P-0015A Enumeration Summary
2023_Enumeration_Summary_ENS.pdf 		Form
CMS-P-0015A Mobility of Beneficiaries
2023_Mobility_MBQ.pdf 		Form
CMS-P-0015A Mobility of Beneficiaries
2023_Mobility_MBQ.pdf 		Form
CMS-P-0015A Post Statement Cost
2023_Post_Statement_Cost_PSQ.pdf 		Form
CMS-P-0015A Post Statement Cost
2023_Post_Statement_Cost_PSQ.pdf 		Form
CMS-P-0015A Access to Care
2024_Access_to_Care_ACQ.pdf 		Form
CMS-P-0015A Access to Care
2024_Access_to_Care_ACQ.pdf 		Form
CMS-P-0015A Chronic Pain
2024_Chronic_Pain_CPQ.pdf 		Form
CMS-P-0015A Chronic Pain
2024_Chronic_Pain_CPQ.pdf 		Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization
2023_Den_Vis_Hear_Care_Utl_DVH.pdf 		Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization
2023_Den_Vis_Hear_Care_Utl_DVH.pdf 		Form
CMS-P-0015A Drug Coverage
2025_Drug_Coverage_RXQ.pdf 		Form
CMS-P-0015A Drug Coverage
2025_Drug_Coverage_RXQ.pdf 		Form
CMS-P-0015A Emergency Utilization
2023_Emergency_Utilization_ERQ.pdf 		Form
CMS-P-0015A Emergency Utilization
2023_Emergency_Utilization_ERQ.pdf 		Form
CMS-P-0015A Health Insurance
2024_Health_Insurance_HIQ.pdf 		Form
CMS-P-0015A Health Insurance
2024_Health_Insurance_HIQ.pdf 		Form
CMS-P-0015A Home Health
2023_Home_Health_Utilization_HHQ.pdf 		Form
CMS-P-0015A Home Health
2023_Home_Health_Utilization_HHQ.pdf 		Form
CMS-P-0015A Housing_Characteristics
2023_Housing_Charcs_HAQ.pdf 		Form
CMS-P-0015A Housing_Characteristics
2023_Housing_Charcs_HAQ.pdf 		Form
CMS-P-0015A Income_and_ Assets
2025_Income_and_Assets_IAQ.pdf 		Form
CMS-P-0015A Income_and_ Assets
2025_Income_and_Assets_IAQ.pdf 		Form
CMS-P-0015A Inpatient Utilization
2023_Inpatient_Utilization_IPQ.pdf 		Form
CMS-P-0015A Inpatient Utilization
2023_Inpatient_Utilization_IPQ.pdf 		Form
CMS-P-0015A Institutional Utilization
2023_Institutional_Util_IUQ.pdf 		Form
CMS-P-0015A Institutional Utilization
2023_Institutional_Util_IUQ.pdf 		Form
CMS-P-0015A Introduction
2025_Introduction_INQ.pdf 		Form
CMS-P-0015A Introduction
2025_Introduction_INQ.pdf 		Form
CMS-P-0015A Medical Provider Utilzation
2023_Medical_Provider_Util_MPQ.pdf 		Form
CMS-P-0015A Medical Provider Utilzation
2023_Medical_Provider_Util_MPQ.pdf 		Form
CMS-P-0015A Nicotine Alcohol
2023_Nicotine_Alcohol_Use_NAQ.pdf 		Form
CMS-P-0015A Nicotine Alcohol
2023_Nicotine_Alcohol_Use_NAQ.pdf 		Form
CMS-P-0015A No Statement Cost
2023_No_Statement_Cost_NSQ.pdf 		Form
CMS-P-0015A No Statement Cost
2023_No_Statement_Cost_NSQ.pdf 		Form
CMS-P-0015A Other Medical Expense
2023_Other_Medical_Expense_OMQ.pdf 		Form
CMS-P-0015A Other Medical Expense
2023_Other_Medical_Expense_OMQ.pdf 		Form
CMS-P-0015A Outpatient Utilization
2023_Outpatient_Utilization_OPQ.pdf 		Form
CMS-P-0015A Outpatient Utilization
2023_Outpatient_Utilization_OPQ.pdf 		Form
CMS-P-0015A Prescribed Medicine Utilization
2023_Prescribed_Med_Util_PMQ.pdf 		Form
CMS-P-0015A Prescribed Medicine Utilization
2023_Prescribed_Med_Util_PMQ.pdf 		Form
CMS-P-0015A Satisfaction Care
2025_Satisfaction_Care_SCQ.pdf 		Form
CMS-P-0015A Satisfaction Care
2025_Satisfaction_Care_SCQ.pdf 		Form
CMS-P-0015A Statement Cost Series
2023_Statement_Cost_Series_STQ.pdf 		Form
CMS-P-0015A Statement Cost Series
2023_Statement_Cost_Series_STQ.pdf 		Form
CMS-P-0015A Beneficiary Knowledge
2025_Beneficiary_Knowledge_KNQ.pdf 		Form
CMS-P-0015A Beneficiary Knowledge
2025_Beneficiary_Knowledge_KNQ.pdf 		Form
CMS-P-0015A Preventive Care
2025_Preventive_Care_PVQ.pdf 		Form
CMS-P-0015A Preventive Care
2025_Preventive_Care_PVQ.pdf 		Form
CMS-P-0015A Usual Source of Care
2024_Usual_Source_Of_Care_USQ.pdf 		Form
CMS-P-0015A Usual Source of Care
2024_Usual_Source_Of_Care_USQ.pdf 		Form
CMS-P-0015A Showcards and Reference Cards
2024CommShowcards508.pdf 		Form
CMS-P-0015A Showcards and Reference Cards
2024CommShowcards508.pdf 		Form
CMS-P-0015A Facility Showcards
2024FacilityShowcards508.pdf 		Form
CMS-P-0015A Facility Showcards
2024FacilityShowcards508.pdf 		Form
CMS-P-0015A Facility Screener
Fac2023_Facility_Screener_FACSCREEN.pdf 		Form
CMS-P-0015A Facility Screener
Fac2023_Facility_Screener_FACSCREEN.pdf 		Form
CMS-P-0015A Residence History Missing Data
Fac2023_Residence_Missing_RHM.pdf 		Form
CMS-P-0015A Residence History Missing Data
Fac2023_Residence_Missing_RHM.pdf 		Form
CMS-P-0015A Residence History
Fac2023_Residence_History_RH.pdf 		Form
CMS-P-0015A Residence History
Fac2023_Residence_History_RH.pdf 		Form
CMS-P-0015A Use of Health Services
Fac2024_Health_Status_HS.pdf 		Form
CMS-P-0015A Use of Health Services
Fac2024_Health_Status_HS.pdf 		Form
CMS-P-0015A Background_Questionnaire
Fac2023_Background_BQ.pdf 		Form
CMS-P-0015A Background_Questionnaire
Fac2023_Background_BQ.pdf 		Form
CMS-P-0015A Background_Questionnaire MIssing Data
Fac2023_Background_Missing_BQM.pdf 		Form
CMS-P-0015A Background_Questionnaire MIssing Data
Fac2023_Background_Missing_BQM.pdf 		Form
CMS-P-0015A Expenditures
Fac2024_Expenditures_EX.pdf 		Form
CMS-P-0015A Expenditures
Fac2024_Expenditures_EX.pdf 		Form
CMS-P-0015A Questionaire Missing Data
Fac2023_Facility_Missing_FQM.pdf 		Form
CMS-P-0015A Questionaire Missing Data
Fac2023_Facility_Missing_FQM.pdf 		Form
CMS-P-0015A Questionaire
Fac2023_Facility_Quex_FQ.pdf 		Form
CMS-P-0015A Questionaire
Fac2023_Facility_Quex_FQ.pdf 		Form
CMS-P-0015A Health_Insurance
Fac2023_Health_Insurance_IN.pdf 		Form
CMS-P-0015A Health_Insurance
Fac2023_Health_Insurance_IN.pdf 		Form
CMS-P-0015A Health_Status
Fac2023_Health_Status_HS.pdf 		Form
CMS-P-0015A Health_Status
Fac2023_Health_Status_HS.pdf 		Form
CMS-P-0015A Cognitive Measures
2023_Cognitive_Measures_CMQ.pdf 		Form
CMS-P-0015A Cognitive Measures
2023_Cognitive_Measures_CMQ.pdf 		Form
CMS-P-0015A HFQ - Health Status and Functioning
2025_Health_Status_HFQ.pdf 		Form
CMS-P-0015A HFQ - Health Status and Functioning
2025_Health_Status_HFQ.pdf 		Form
CMS-P-0015A Physical_Measures
2024_Physical_Measures_PXQ.pdf 		Form
CMS-P-0015A Physical_Measures
2024_Physical_Measures_PXQ.pdf 		Form
P-0015A COVID-19 Questionnaire Specifications
Fac2024_COVID_19_Bene_CV.pdf 		Form
P-0015A COVID-19 Questionnaire Specifications
Fac2024_COVID_19_Bene_CV.pdf 		Form
P-0015A COVID-19 Facility-Level Supplement
2024_COVID_19_CVQ.pdf 		Form
P-0015A COVID-19 Facility-Level Supplement
2024_COVID_19_CVQ.pdf 		Form
CMS-P-0015A Use of Health Services Section Specifications
Fac2023_Use_Health_Services_US.pdf 		Form
CMS-P-0015A Use of Health Services Section Specifications
Fac2023_Use_Health_Services_US.pdf 		Form
CMS-P-0015A Telemedicine Questionnaire
2024_Telemedicine_TLQ.pdf 		Form
CMS-P-0015A Telemedicine Questionnaire
2024_Telemedicine_TLQ.pdf 		Form
CMS-P-0015A Physical Measures Frequently Asked Questions (FAQ) Sheet
ComPhysicalMeasuresFAQ.pdf 		Form
CMS-P-0015A Physical Measures Frequently Asked Questions (FAQ) Sheet
ComPhysicalMeasuresFAQ.pdf 		Form
CMS-P-0015A Immunization
2025_Immunization_IMQ.pdf 		Form
CMS-P-0015A Immunization
2025_Immunization_IMQ.pdf 		Form
CMS-P-0015A Health_Status
2025_Health_Status_HFQ.pdf 		Form
CMS-P-0015A Health_Status
2025_Health_Status_HFQ.pdf 		Form
CMS-P-0015A Interviewer_Remarks
Fac2023_Interviewer_Remarks_IR.pdf 		Form
CMS-P-0015A Interviewer_Remarks
Fac2023_Interviewer_Remarks_IR.pdf 		Form
Attachment A - Revised Questionnaires.pdf
Track change versions (DIQ, INQ, SCQ)		IC Document
Attachment A - Revised Questionnaires.pdf
Track change versions (DIQ, INQ, SCQ)		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form P-0015A Yes Yes Fillable Fileable
Form P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable
Form CMS-P-0015A Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 35,015 0 0 0 0 35,015
Annual IC Time Burden (Hours) 35,206 0 -138 0 0 35,344
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Track change versions (DIQ, INQ, SCQ) 04/08/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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