OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Survey Mode Experiment (CMS-10105)

OMB 0938-0926 · HHS/CMS.

OMB 0938-0926

CMS designed the ICH CAHPS survey and measures to enable dialysis patients to make more informed decisions when choosing a dialysis facility, to aid facilities in their quality improvement efforts, and to help CMS monitor the performance of dialysis facilities. CMS publicly reports clinical quality measures and patient experience of care survey results for kidney dialysis centers on Care Compare on Medicare.gov. Public reporting of ICH CAHPS data is refreshed in April and October, with each refresh including a rolling average of the two most recent survey periods available. Both clinical and patient experience of care quality measures enable patients with end-stage renal disease (ESRD) to make informed decisions when choosing a dialysis facility. The ICH CAHPS survey fulfills a requirement of the ESRD Quality Incentive Program (QIP).

The latest form for The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Survey Mode Experiment (CMS-10105) expires 2029-02-28 and is listed under ICR 202509-0938-017.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10105 Medicare In-Center and Home Dialysis Survey (Spanish)Form and Instruction
Form CMS-10105 Medicare In-Center and Home Dialysis Survey (English)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chinese)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chinese)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (English)Form and Instruction
Public Comment - Center for the Study of Services.pdfPublic Comments
Mayo.edu.pdfPublic Comments
Response to Comment on ICH CAHPS Mode Experiment package_10.13.26.docxSupplementary Document
Survey-Crosswalk-Current-vs-ICH-Home-508_RevNov2026.pdfSupplementary Document
CMS-10105_ICH-CAHPS-ModeExperiment-Supporting_Statement_part_B_.docxSupporting Statement B
CMS-10105_ICH CAHPS Mode Experiment_Supporting_Statement_part_A.docxSupporting Statement A
Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey Form and Instruction
Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Other-Sample Cover Letter (English)

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202611-0938-008 Revision of a currently approved collection 2026-11-06
202509-0938-017 Revision of a currently approved collection 2025-11-26
202507-0938-021 Revision of a currently approved collection 2025-07-16
202504-0938-001 Extension without change of a currently approved collection 2025-04-29
202207-0938-007 Extension without change of a currently approved collection 2022-07-18 Approved with change
201908-0938-009 Extension without change of a currently approved collection 2019-11-19 Approved without change
201609-0938-014 Revision of a currently approved collection 2016-09-28 Approved with change
201307-0938-002 Reinstatement with change of a previously approved collection 2013-07-09 Approved without change
200407-0938-004 New collection (Request for a new OMB Control Number) 2004-07-23 Approved with change