Information Collection

CAHPS for MIPS Survey Beneficiary Participation

IC 206234 under ICR 202102-0938-018 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Beneficiary Participation Form
Appendix B1 2021_survey_initial_cover_letter_english_clean.pdf Instruction
Appendix B1 2021_survey_initial_cover_letter_english_clean.pdf Instruction
Appendix C1 2021_survey_second_cover_letter_english_clean.pdf Instruction
Appendix C1 2021_survey_second_cover_letter_english_clean.pdf Instruction
CMS-10450 Mail Survey Appendix A1 2021_mail_survey.pdf Form
CMS-10450 Mail Survey Appendix A1 2021_mail_survey.pdf Form
CMS-10450 CAHPS for MIPS CATI Script Appendix D1 2021_CAHPS_for_MIPS_CATI_Script (1).pdf Form and Instruction
CMS-10450 CAHPS for MIPS CATI Script Appendix D1 2021_CAHPS_for_MIPS_CATI_Script (1).pdf Form and Instruction
Appendix A2 Mail Survey Crosswalk .pdf Mail Survey Crosswalk IC Document
Appendix A2 Mail Survey Crosswalk .pdf Mail Survey Crosswalk IC Document
Appendix B2 2021_Survey Initial Cover Letter Crosswalk 2020-12-29 .pdf Suvey Initial Letter Crosswalk IC Document
Appendix B2 2021_Survey Initial Cover Letter Crosswalk 2020-12-29 .pdf Suvey Initial Letter Crosswalk IC Document
Appendix C2 Survey Second Cover Letter Crosswalk 2020-12-29 .pdf Survey Second Letter Crosswalk IC Document
Appendix C2 Survey Second Cover Letter Crosswalk 2020-12-29 .pdf Survey Second Letter Crosswalk IC Document
Appendix D2 CAHPS for MIPS CATI Script Crosswalk.pdf CAHPS for MIPS CATI Script Crosswalk IC Document
Appendix D2 CAHPS for MIPS CATI Script Crosswalk.pdf CAHPS for MIPS CATI Script Crosswalk IC Document

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10450	Mail Survey	Appendix A1 2021_mail_survey.pdf	Yes	Yes	Fillable Fileable
Instruction			Appendix B1 2021_survey_initial_cover_letter_english_clean.pdf	Yes	Yes	Fillable Fileable
Instruction			Appendix C1 2021_survey_second_cover_letter_english_clean.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	CAHPS for MIPS CATI Script	Appendix D1 2021_CAHPS_for_MIPS_CATI_Script (1).pdf	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: 29,952	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	29,952	-9,087	39,039
Annual IC Time Burden (Hours)	6,540	-1,853	8,393
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Mail Survey Crosswalk	Appendix A2 Mail Survey Crosswalk .pdf	02/26/2021
Suvey Initial Letter Crosswalk	Appendix B2 2021_Survey Initial Cover Letter Crosswalk 2020-12-29 .pdf	02/26/2021
Survey Second Letter Crosswalk	Appendix C2 Survey Second Cover Letter Crosswalk 2020-12-29 .pdf	02/26/2021
CAHPS for MIPS CATI Script Crosswalk	Appendix D2 CAHPS for MIPS CATI Script Crosswalk.pdf	02/26/2021

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