Information Collection

HOPDs/ASCs Patient Records

IC 216391 under ICR 202602-0938-015 · OMB 0938-1240.

Documents and Forms

Document Name Document Type
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 and Instruction
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 (Telephone Script) (Spanish) HOPDs/ASCs Patient Records Form and Instruction
Form CMS-10500 OAS CAHPS (Web Survey Screenshots) (Spanish) 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) Attachment A-OAS CAHPS Survey Instrument (Mail).docx Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) Attachment B-OAS CAHPS Survey Instrument (Telephone).docx Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) Attachment C-OAS CAHPS Survey Instrument (Web).docx Form and Instruction
CMS-10500 OAS CAHPS - Spanish Attachment E1-OAS CAHPS Survey Instrument_Mail_Spanish.docx Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) (Spanish) Attachment E2-OAS CAHPS Survey Instrument_Telephone_Spanish.docx Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) (Spanish) Attachment E3-OAS CAHPS Survey Instrument_Web_Spanish.docx 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
Attachment D1-OAS CAHPS Mail Cover Letters.docx Cover Letters IC Document
Attachment D2-OAS CAHPS Web Survey Invitation Letters.docx Letter Invitation for Web Survey IC Document
Attachment D3-OAS CAHPS Web Survey Invitation Emails.docx E-mail Invitation for Web Survey (1st Contact) IC Document
Attachment D4-OAS CAHPS Web+Mail Follow-up Cover Letter.docx 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 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

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10500	OAS CAHPS (Mail Survey)	Attachment A-OAS CAHPS Survey Instrument (Mail).docx	No		Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Telephone Script)	Attachment B-OAS CAHPS Survey Instrument (Telephone).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Web Survey Screenshots)	Attachment C-OAS CAHPS Survey Instrument (Web).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS - Spanish	Attachment E1-OAS CAHPS Survey Instrument_Mail_Spanish.docx	No		Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Telephone Script) (Spanish)	Attachment E2-OAS CAHPS Survey Instrument_Telephone_Spanish.docx	No		Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Web Survey Screenshots) (Spanish)	Attachment E3-OAS CAHPS Survey Instrument_Web_Spanish.docx	No		Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS - Korean	Attachment E4 - OAS CAHPS - Korean.pdf	No		Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS - Russian	Attachment E5 - OAS CAHPS - Russian.pdf	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: 8,427	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,427	-1,816	10,243
Annual IC Time Burden (Hours)	235,956	-50,848	286,804
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letters	Attachment D1-OAS CAHPS Mail Cover Letters.docx	02/13/2026
Letter Invitation for Web Survey	Attachment D2-OAS CAHPS Web Survey Invitation Letters.docx	02/13/2026
E-mail Invitation for Web Survey (1st Contact)	Attachment D3-OAS CAHPS Web Survey Invitation Emails.docx	02/13/2026
Followup Web Survey Invitation Letter	Attachment D4-OAS CAHPS Web+Mail Follow-up Cover Letter.docx	02/13/2026
Follow up Web Survey Invitation Email	OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf	02/23/2024
Web with Mail Followup_Questionnaire Cover Letter	OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf	02/23/2024
Prenote Letter for Telephone Only	OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf	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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