Information Collection

CAHPS for MIPS Survey Beneficiary Participation

IC 206234 under ICR 202607-0938-006 · OMB 0938-1222.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10450 Mail Survey CAHPS for MIPS Survey Beneficiary Participation	Form
Form CMS-10450 CAHPS for MIPS CATI Script CAHPS for MIPS Survey Beneficiary Participation	Form and Instruction
Form CMS-10450 Mail- Survey CAHPS for MIPS Survey Beneficiary Participation	Form and Instruction
Form CMS-10450 CATI-Script CAHPS for MIPS Survey Beneficiary Participation	Form and Instruction
Form CMS-10450 Web-Survey CAHPS for MIPS Survey Beneficiary Participation	Form and Instruction
Form CMS-10450 Web-Survey - Spanish CAHPS for MIPS Survey Beneficiary Participation	Form and Instruction
Appendix-F1-Mail-Initial-Letter.pdf	Instruction
Appendix-F2-Mail-Second-Letter.pdf	Instruction
Appendix-F3-Mail-Initial-Letter - Spanish.pdf	Instruction
Appendix-F4-Mail-Second-Letter - Spanish.pdf	Instruction
Appendix-D1-Web-Invitation-Email.pdf	Instruction
Appendix-D2-Web-Invitation-Letter.pdf	Instruction
Appendix-D3-Web-Reminder-Email.pdf	Instruction
Appendix-D4-Web-Invitation-Email - Spanish.pdf	Instruction
Appendix-D5-Web-Invitation-Letter - Spanish.pdf	Instruction
Appendix-D6-Web-Reminder-Email - Spanish.pdf	Instruction
CMS-10450 Mail Survey Appendix-E1-Mail-Survey.pdf	Form
CMS-10450 CAHPS for MIPS CATI Script Appendix-G1-CATI-Script.pdf	Form and Instruction
CMS-10450 Mail- Survey Appendix-E2-Mail-Survey - Spanish.pdf	Form and Instruction
CMS-10450 CATI-Script Appendix-G2-CATI-Script - Spanish.pdf	Form and Instruction
CMS-10450 Web-Survey Appendix-C1-Web-Survey.pdf	Form and Instruction
CMS-10450 Web-Survey - Spanish Appendix-C2-Web-Survey - Spanish.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10450	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		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: 26,700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	26,700	1,200	25,500
Annual IC Time Burden (Hours)	5,829	262	5,567
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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