Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152 New 666120 219820 0 Form and Instruction CMS-10203 Medicare HOS 2013 Questionnaire (English)
Form and Instruction CMS-10203 Medicare HOS-Modified 2013 Questionnaire (English)
Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203) Removed 0 0 0 Other-Other: Medicare HOS - Modified 2010 Questionnaire: English
Other- Other: Medicare HOS - Modified 2010 Questionnaire: Spanish
Other- Other: Medicare HOS - Modified 2010 Questionnaire: Chinese
Other- Other: Other: Medicare HOS - Modified 2010 Questionnaire: English
Other- Other: Other: Medicare HOS - Modified 2010 Questionnaire: Spanish
Other- Other: Other: Medicare HOS - Modified 2010 Questionnaire: Chinese
Total burden requested under this ICR: 666120 219820 0  
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