Information Collection

Medicare Beneficiary and Family-Centered Satisfaction Survey

IC 201543 under ICR 202607-0938-009 · OMB 0938-1177.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10393 Attachment B: Beneficiary Experience Survey Medicare Beneficiary and Family-Centered Satisfaction Survey	Form and Instruction
CMS-10393 Attachment B: Beneficiary Experience Survey CMS-10393_Attachment B_Experience Survey_04.23.2026 Word 508.docx	Form and Instruction
CMS-10393_Attachment A_Related Legislation_06.29.2023_508.pdf Legislation	IC Document
CMS 10393 PRA Package Revisions Crosswalk Changes.pdf Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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-10393				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	9,000	9,000
Annual IC Time Burden (Hours)	2,250	2,250
Annual IC Cost Burden (Dollars)	31,365	31,365

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Legislation		10/27/2023
Crosswalk		07/24/2026

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

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