Information Collection

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

IC 8171 under ICR 202511-0938-005 · OMB 0938-0568.

Documents and Forms

Document Name Document 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 Health_Status 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 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 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 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
Form CMS-P-0015A Debt Questionaire 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 2026_Demographics_Income_DIQ.pdf Form
CMS-P-0015A Demographic Income 2026_Demographics_Income_DIQ.pdf Form
CMS-P-0015A End Questionaire 2024_End_END.pdf Form
CMS-P-0015A End Questionaire 2024_End_END.pdf Form
CMS-P-0015A Enumeration Summary 2024_Enumeration_Summary_ENS.pdf Form
CMS-P-0015A Enumeration Summary 2024_Enumeration_Summary_ENS.pdf Form
CMS-P-0015A Mobility of Beneficiaries 2024_Mobility_MBQ.pdf Form
CMS-P-0015A Mobility of Beneficiaries 2024_Mobility_MBQ.pdf Form
CMS-P-0015A Post Statement Cost 2024_Post_Statement_Cost_PSQ.pdf Form
CMS-P-0015A Post Statement Cost 2024_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 2024_Den_Vis_Hear_Care_Utl_DVH.pdf Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2024_Den_Vis_Hear_Care_Utl_DVH.pdf Form
CMS-P-0015A Drug Coverage 2026_Drug_Coverage_RXQ.pdf Form
CMS-P-0015A Drug Coverage 2026_Drug_Coverage_RXQ.pdf Form
CMS-P-0015A Emergency Utilization 2024_Emergency_Utilization_ERQ.pdf Form
CMS-P-0015A Emergency Utilization 2024_Emergency_Utilization_ERQ.pdf Form
CMS-P-0015A Health Insurance 2026_Health_Insurance_HIQ.pdf Form
CMS-P-0015A Health Insurance 2026_Health_Insurance_HIQ.pdf Form
CMS-P-0015A Home Health 2024_Home_Health_Util_HHQ.pdf Form
CMS-P-0015A Home Health 2024_Home_Health_Util_HHQ.pdf Form
CMS-P-0015A Housing_Characteristics 2024_Housing_Charcs_HAQ.pdf Form
CMS-P-0015A Housing_Characteristics 2024_Housing_Charcs_HAQ.pdf Form
CMS-P-0015A Income_and_ Assets 2026_Income_and_Assets_IAQ.pdf Form
CMS-P-0015A Income_and_ Assets 2026_Income_and_Assets_IAQ.pdf Form
CMS-P-0015A Inpatient Utilization 2024_Inpatient_Utilization_IPQ.pdf Form
CMS-P-0015A Inpatient Utilization 2024_Inpatient_Utilization_IPQ.pdf Form
CMS-P-0015A Institutional Utilization 2024_Institutional_Util_IUQ.pdf Form
CMS-P-0015A Institutional Utilization 2024_Institutional_Util_IUQ.pdf Form
CMS-P-0015A Introduction 2026_Introduction_INQ.pdf Form
CMS-P-0015A Introduction 2026_Introduction_INQ.pdf Form
CMS-P-0015A Medical Provider Utilzation 2024_Medical_Provider_Util_MPQ.pdf Form
CMS-P-0015A Medical Provider Utilzation 2024_Medical_Provider_Util_MPQ.pdf Form
CMS-P-0015A Nicotine Alcohol 2024_Nicotine_Alcohol_Use_NAQ.pdf Form
CMS-P-0015A Nicotine Alcohol 2024_Nicotine_Alcohol_Use_NAQ.pdf Form
CMS-P-0015A No Statement Cost 2024_No_Statement_Cost_NSQ.pdf Form
CMS-P-0015A No Statement Cost 2024_No_Statement_Cost_NSQ.pdf Form
CMS-P-0015A Other Medical Expense 2024_Other_Medical_Expense_OMQ.pdf Form
CMS-P-0015A Other Medical Expense 2024_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 2024_Prescribed_Med_Util_PMQ.pdf Form
CMS-P-0015A Prescribed Medicine Utilization 2024_Prescribed_Med_Util_PMQ.pdf Form
CMS-P-0015A Satisfaction Care 2026_Satisfaction_Care_SCQ.pdf Form
CMS-P-0015A Satisfaction Care 2026_Satisfaction_Care_SCQ.pdf Form
CMS-P-0015A Statement Cost Series 2024_Statement_Cost_Series_STQ.pdf Form
CMS-P-0015A Statement Cost Series 2024_Statement_Cost_Series_STQ.pdf Form
CMS-P-0015A Beneficiary Knowledge 2026_Beneficiary_Knowledge_KNQ.pdf Form
CMS-P-0015A Beneficiary Knowledge 2026_Beneficiary_Knowledge_KNQ.pdf Form
CMS-P-0015A Preventive Care 2026_Preventive_Care_PVQ.pdf Form
CMS-P-0015A Preventive Care 2026_Preventive_Care_PVQ.pdf Form
CMS-P-0015A Usual Source of Care 2026_Usual_Source_Of_Care_USQ.pdf Form
CMS-P-0015A Usual Source of Care 2026_Usual_Source_Of_Care_USQ.pdf Form
CMS-P-0015A Showcards and Reference Cards 2026CommShowcards508.pdf Form
CMS-P-0015A Showcards and Reference Cards 2026CommShowcards508.pdf Form
CMS-P-0015A Facility Showcards 2026FacilityShowcards508.pdf Form
CMS-P-0015A Facility Showcards 2026FacilityShowcards508.pdf Form
CMS-P-0015A Facility Screener Attachment 3. Fac2024_Facility_Screener_FACSCREEN.pdf Form
CMS-P-0015A Facility Screener Attachment 3. Fac2024_Facility_Screener_FACSCREEN.pdf Form
CMS-P-0015A Residence History Missing Data Fac2024_Residence_Missing_RHM.pdf Form
CMS-P-0015A Residence History Missing Data Fac2024_Residence_Missing_RHM.pdf Form
CMS-P-0015A Residence History Fac2024_Residence_History_RH.pdf Form
CMS-P-0015A Residence History Fac2024_Residence_History_RH.pdf Form
CMS-P-0015A Health_Status Fac2025_Health_Status_HS.pdf Form
CMS-P-0015A Health_Status Fac2025_Health_Status_HS.pdf Form
CMS-P-0015A Background_Questionnaire Fac2024_Background_BQ.pdf Form
CMS-P-0015A Background_Questionnaire Fac2024_Background_BQ.pdf Form
CMS-P-0015A Background_Questionnaire MIssing Data Fac2024_Background_Missing_BQM.pdf Form
CMS-P-0015A Background_Questionnaire MIssing Data Fac2024_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 Fac2024_Facility_Missing_FQM.pdf Form
CMS-P-0015A Questionaire Missing Data Fac2024_Facility_Missing_FQM.pdf Form
CMS-P-0015A Questionaire Fac2024_Facility_Quex_FQ.pdf Form
CMS-P-0015A Questionaire Fac2024_Facility_Quex_FQ.pdf Form
CMS-P-0015A Health_Insurance Fac2024_Health_Insurance_IN.pdf Form
CMS-P-0015A Health_Insurance Fac2024_Health_Insurance_IN.pdf Form
CMS-P-0015A Cognitive Measures 2026_Cognitive_Measures_CMQ.pdf Form
CMS-P-0015A Cognitive Measures 2026_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 Use of Health Services Section Specifications Fac2024_Use_Health_Services_US.pdf Form
CMS-P-0015A Use of Health Services Section Specifications Fac2024_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 Immunization 2026_Immunization_IMQ.pdf Form
CMS-P-0015A Immunization 2026_Immunization_IMQ.pdf Form
CMS-P-0015A Health_Status 2026_Health_Status_HFQ.pdf Form
CMS-P-0015A Health_Status 2026_Health_Status_HFQ.pdf Form
CMS-P-0015A Interviewer_Remarks Fac2024_Interviewer_Remarks_IR.pdf Form
CMS-P-0015A Interviewer_Remarks Fac2024_Interviewer_Remarks_IR.pdf Form
CMS-P-0015A Debt Questionaire 2026_Debt_DBQ.pdf Form
CMS-P-0015A Debt Questionaire 2026_Debt_DBQ.pdf Form
2026 MCBS Item Revision Crosswalk_06242025.pdf Item Crosswalk (60-day) IC Document
2026 MCBS Item Revision Crosswalk_06242025.pdf Item Crosswalk (60-day) IC Document
Item Level Crosswalk_09292025.pdf Item Crosswalk (30-day) IC Document
Item Level Crosswalk_09292025.pdf Item Crosswalk (30-day) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-P-0015A	Cost Payment Summary	2024_Cost_Payment_Summary_CPS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Demographic Income	2026_Demographics_Income_DIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	End Questionaire	2024_End_END.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Enumeration Summary	2024_Enumeration_Summary_ENS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Mobility of Beneficiaries	2024_Mobility_MBQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Post Statement Cost	2024_Post_Statement_Cost_PSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Access to Care	2024_Access_to_Care_ACQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Chronic Pain	2024_Chronic_Pain_CPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Dental, Vision, and Hearing Care Utilization	2024_Den_Vis_Hear_Care_Utl_DVH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Drug Coverage	2026_Drug_Coverage_RXQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Emergency Utilization	2024_Emergency_Utilization_ERQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health Insurance	2026_Health_Insurance_HIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Home Health	2024_Home_Health_Util_HHQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Housing_Characteristics	2024_Housing_Charcs_HAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Income_and_ Assets	2026_Income_and_Assets_IAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Inpatient Utilization	2024_Inpatient_Utilization_IPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Institutional Utilization	2024_Institutional_Util_IUQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Introduction	2026_Introduction_INQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Medical Provider Utilzation	2024_Medical_Provider_Util_MPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Nicotine Alcohol	2024_Nicotine_Alcohol_Use_NAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	No Statement Cost	2024_No_Statement_Cost_NSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Other Medical Expense	2024_Other_Medical_Expense_OMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Outpatient Utilization	2023_Outpatient_Utilization_OPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Prescribed Medicine Utilization	2024_Prescribed_Med_Util_PMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Satisfaction Care	2026_Satisfaction_Care_SCQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Statement Cost Series	2024_Statement_Cost_Series_STQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Beneficiary Knowledge	2026_Beneficiary_Knowledge_KNQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Preventive Care	2026_Preventive_Care_PVQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Usual Source of Care	2026_Usual_Source_Of_Care_USQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Showcards and Reference Cards	2026CommShowcards508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Facility Showcards	2026FacilityShowcards508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Facility Screener	Attachment 3. Fac2024_Facility_Screener_FACSCREEN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History Missing Data	Fac2024_Residence_Missing_RHM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History	Fac2024_Residence_History_RH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Status	Fac2025_Health_Status_HS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire	Fac2024_Background_BQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire MIssing Data	Fac2024_Background_Missing_BQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Expenditures	Fac2024_Expenditures_EX.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire Missing Data	Fac2024_Facility_Missing_FQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire	Fac2024_Facility_Quex_FQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Insurance	Fac2024_Health_Insurance_IN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Cognitive Measures	2026_Cognitive_Measures_CMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	HFQ - Health Status and Functioning	2025_Health_Status_HFQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Use of Health Services Section Specifications	Fac2024_Use_Health_Services_US.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Telemedicine Questionnaire	2024_Telemedicine_TLQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Immunization	2026_Immunization_IMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Status	2026_Health_Status_HFQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Interviewer_Remarks	Fac2024_Interviewer_Remarks_IR.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Debt Questionaire	2026_Debt_DBQ.pdf	Yes	Yes	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: 13,568	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	35,015	0	35,015
Annual IC Time Burden (Hours)	32,258	-2,948	35,206
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Item Crosswalk (60-day)	2026 MCBS Item Revision Crosswalk_06242025.pdf	11/19/2025
Item Crosswalk (30-day)	Item Level Crosswalk_09292025.pdf	11/19/2025

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

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