Information Collection

CAHPS for MIPS Survey Vendor Application

IC 227776 under ICR 201807-0938-014 · OMB 0938-1222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1222 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10450 CAHPS for MIPS Survey Vendor Application Form and Instruction
CMS-10450 Appendix F: Vendor Form Appendix F 2019-CAHPS-for-MIPS-Survey-Vendors-Application (rev OSORA PRA).docx Form and Instruction
CMS-10450 Appendix H: Vendor Attestation Appendix H CAHPS for MIPS Vendor Attestation Statement 12.04.17 (rev OSORA PRA).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CAHPS for MIPS Survey Vendor Application	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10450	Appendix F: Vendor Form	Appendix F 2019-CAHPS-for-MIPS-Survey-Vendors-Application (rev OSORA PRA).docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	Appendix H: Vendor Attestation	Appendix H CAHPS for MIPS Vendor Attestation Statement 12.04.17 (rev OSORA PRA).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.