Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
(CMS-10546) Survey for Long-Term (LT) and Post-Acute Care (PAC) Electronic Health Records (EHR) and Health Information Exchange (HIE) Adoption Unchanged 34328 11443 0 Form and Instruction CMS-10546 Utilization of Health Information Technology in Post-Acute Care Settings
(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey Unchanged 36 72 0 Form and Instruction CMS-10560 Focus Group Eligibility Screener, Consent form and Protocol
(CMS-10585) QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project New 200 34 0 Form and Instruction CMS-10585 Quality Net User Survey
(CMS-10588) Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project New 40 32 0 Form and Instruction CMS-10588 Usability Test Script
(CMS-10590) QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project. New 500 83 0 Form and Instruction CMS-10590 Quality Net User Survey
(CMS-10591) Cognitive Testing for the Marketplace Dental Survey New 48 48 0 Form and Instruction CMS-10591 Marketplace Dental Survey Cognitive Testing Eligibility Screener
Beneficiary Contact Center Customer Satisfaction Survey Unchanged 145000 5776 0 Form and Instruction CMS-10415 IVR Phone Script for Survey
Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557) Unchanged 60 1 0 Form CMS-10557 Pilot Test Registration Tool
Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557) Unchanged 46 4035 0 Form CMS-10557 PACE Pilot Test Evaluation
Other-Recruitment Reminder Letter
Other-Recruitment Letter
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) Modified 384 77 0 Form and Instruction GenIC #5 ESRD Grievant
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2 New 384 77 0 Form and Instruction GenIC#5 ESRD Greivant Satisfaction Survey
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs Unchanged 100000 417 0 Form and Instruction 0938-1185 Stakeholder Training Forms
Health Care Payment Learning and Action Network (CMS-10559) Unchanged 1000 100 0 Form and Instruction CMS-10559 Health Care Payment Learning and Action Network
Health Care Payment Learning and Action Network Registration (CMS-10584) New 5000 167 0 Form and Instruction CMS-10584 LAN Summit Registration Form
Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6) Unchanged 30 10 0 Form and Instruction Beneficiary Telephone Interview Script CMS-10396
Other-Medicare Beneficiary Mailed Solicitation Letter
Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396) New 50 17 0 Other-Beneficiary Solicitation Letter
Form and Instruction CMS-10396 Telephone Interview Script
Other-Visual Aid #1 – Medicare & You 2016 MTM Pages
Other-Visual Aid #2 – Medication Action Plan Mockup
Other-Visual Aid #3 – Personal Medication List Mockup
Peer Coach Assessment Unchanged 36 6 0 Instruction
Other-Link to Instrument
Quality Reporting Process Survey (CMS-10562) Unchanged 50 25 0 Form and Instruction CMS-10562 Quality Reporting Process Survey
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project Unchanged 90 106 0 Form and Instruction CMS-10534 Cognitive Interview Guide, Screener and Consent Forms
Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project Unchanged 90 135 0 Form and Instruction CMS-10533 Consumer Usability Testing Guide, and Screeners
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 287372 22661 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
To view an IC, click on IC Title