Information Collection

CAHPS for MIPS Survey Vendor Application

IC 227776 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 Appendix B: Vendor Form CAHPS for MIPS Survey Vendor Application	Form and Instruction
CMS-10450 Appendix B: Vendor Form Appendix-B-Vendor-Participation-Form.pdf	Form and Instruction
CAHPS-For-MIPS-Summary-Of-Changes.pdf Summary of Changes	IC Document
MIPS - Crosswalk.xlsx Crosswalk for Vendor Application	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.1400

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 and Instruction	CMS-10450				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	10	0	10
Annual IC Time Burden (Hours)	110	10	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Summary of Changes		07/17/2026
Crosswalk for Vendor Application		07/17/2026

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

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