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Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Facility Screening Interview Script for Meeting with Facility Administrators attachment 05.zip Yes Yes Printable Only
Other-MCBS Facility Round 55 Instrument attachment 06.zip Yes Yes Printable Only
Other-CQuestionnaire Layout CQuestionnaireLayout.pdf.pdf Yes Yes Printable Only
Other-Spanish AC Round 55.pdf Yes Yes Printable Only
Other-Spanish CPS Round 55.pdf Yes Yes Printable Only
Other-Spanish DU Round 55.pdf Yes Yes Printable Only
Other-Spanish ER Round 55.pdf Yes Yes Printable Only
Other-Spanish HH & HHS Round 55.pdf Yes Yes Printable Only
Other-Spanish HIST & HIT Round 55.pdf Yes Yes Printable Only
Other-Spanish IU Round 55.pdf Yes Yes Printable Only
Other-Spanish NS Round 55.pdf Yes Yes Printable Only
Other-Spanish PM & PMS Round 55.pdf Yes Yes Printable Only
Other-Spanish AV Round 55.pdf Yes Yes Printable Only
Other-Spanish DI Round 52.pdf Yes Yes Printable Only
Other-Spanish EN & ENS Round 55.pdf Yes Yes Printable Only
Other-Spanish HA Round 55.pdf Yes Yes Printable Only
Other-Spanish HI & HIS Round 55.pdf Yes Yes Printable Only
Other-Spanish IN & INS Round 55.pdf Yes Yes Printable Only
Other-Spanish MC Round 55.pdf Yes Yes Printable Only
Other-Spanish OM Round 55.pdf Yes Yes Printable Only
Other-Spanish PS Round 55.pdf Yes Yes Printable Only
Other-Spanish STRound55.pdf Yes Yes Printable Only
Other-Spanish CL Round 55.pdf Yes Yes Printable Only
Other-Spanish DM Round 55.pdf Yes Yes Printable Only
Other-Spanish END Round 55.pdf Yes Yes Printable Only
Other-Spanish HF Round 55.pdf Yes Yes Printable Only
Other-Spanish HISMC & HIMC Round 55.pdf Yes Yes Printable Only
Other-Spanish IP Round 55.pdf Yes Yes Printable Only
Other-Spanish MP Round 55.pdf Yes Yes Printable Only
Other-Spanish OP Round 55.pdf Yes Yes Printable Only
Other-Spanish SCRound55.pdf Yes Yes Printable Only
Other-Spanish USRound55.pdf Yes Yes Printable Only
Other-Spanish Showcards DI2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards DM1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards glos-med abbrv dose-strength med-Spanish.pdf Yes Yes Printable Only
Other-Spanish Showcards HA3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF6-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH5-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HIMC1-Spanish.pdf Yes Yes Printable Only
Other-Spanish Showcards IA1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards 2010 Calendar-Spanish.pdf Yes Yes Printable Only
Other-Spanish Showcards DI3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards DU-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HA1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF7-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HI3-Sp _not match_.pdf Yes Yes Printable Only
Other-Spanish Showcards HIMC2A-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HIT1_front & back_-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards IA2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards DI1A-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards DI-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards ENS-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HA2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HF5-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HH4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HI4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards HIMC2-SP.pdf Yes Yes Printable Only
Other-Spanish Showcards HIT2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards IA3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards IA3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN6-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN13-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP5-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards PA1_PA2_PA4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards PM1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards RX1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards ST2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards US2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards IU-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN9-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM5-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards PD2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards ref card for med specialty-SP.pdf Yes Yes Printable Only
Other-Spanish Showcards SC1A-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards ST1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards US1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards IA4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN7-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards KN14-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards MP3-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards OM4-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards PD1-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards pronunc guide-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards RX2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards SC2-Sp.pdf Yes Yes Printable Only
Other-Spanish Showcards statement terms glos-Spanish.pdf Yes Yes Printable Only
Other-English Showcards 2010 Calendar-Eng.pdf Yes Yes Printable Only
Other-English Showcards DI3-Eng.pdf Yes Yes Printable Only
Other-English Showcards DU-Eng.pdf Yes Yes Printable Only
Other-English Showcards Exit Screens_Showcard.pdf Yes Yes Printable Only
Other-English Showcards HA2-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF2-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF5-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH1-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH4-Eng.pdf Yes Yes Printable Only
Other-English Showcards HI3 E-K.pdf Yes Yes Printable Only
Other-English Showcards HI3 O-S.pdf Yes Yes Printable Only
Other-English Showcards HIMC1-Eng.pdf Yes Yes Printable Only
Other-English Showcards HIMC-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA1a-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA Glossary.pdf Yes Yes Printable Only
Other-English Showcards IA2-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN1-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN6-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN13-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP1-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP4-Eng.pdf Yes Yes Printable Only
Other-English Showcards OM2-Eng.pdf Yes Yes Printable Only
Other-Spanish Showcards OM5-Eng.pdf Yes Yes Printable Only
Other-English Showcards PD2-Eng.pdf Yes Yes Printable Only
Other-English Showcards R56 Continuing Showcard List.pdf Yes Yes Printable Only
Other-English Showcards RX2-Eng.pdf Yes Yes Printable Only
Other-English Showcards SC2-Eng.pdf Yes Yes Printable Only
Other-English Showcards spec keys for CAPI.pdf Yes Yes Printable Only
Other-English Showcards state abbrv.pdf Yes Yes Printable Only
Other-English Showcards US2-Eng.pdf Yes Yes Printable Only
Other-English Showcards DI1A-Eng.pdf Yes Yes Printable Only
Other-English Showcards DI-Eng.pdf Yes Yes Printable Only
Other-English Showcards ENS-Eng.pdf Yes Yes Printable Only
Other-English Showcards gloss of pres med abbrv.pdf Yes Yes Printable Only
Other-English Showcards HA3-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF3-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF6-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH2-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH5-Eng.pdf Yes Yes Printable Only
Other-English Showcards HI3 L-M.pdf Yes Yes Printable Only
Other-English Showcards HI3 T-W.pdf Yes Yes Printable Only
Other-English Showcards HIMC2A-Eng.pdf Yes Yes Printable Only
Other-English Showcards HIT1_front & back_-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA1a-Sp.pdf Yes Yes Printable Only
Other-English Showcards IA3-Eng.pdf Yes Yes Printable Only
Other-English Showcards Interrupt Menu Showcard .pdf Yes Yes Printable Only
Other-English Showcards KN2-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN7-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN14-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP2-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP5-Eng.pdf Yes Yes Printable Only
Other-English Showcards OM3-Eng.pdf Yes Yes Printable Only
Other-English Showcards PA1_PA2_PA4.pdf Yes Yes Printable Only
Other-English Showcards PM1-Eng.pdf Yes Yes Printable Only
Other-English Showcards Ref card for med provider.pdf Yes Yes Printable Only
Other-English Showcards SC1A-Eng.pdf Yes Yes Printable Only
Other-English Showcards SC3-Eng.pdf Yes Yes Printable Only
Other-English Showcards ST1-Eng.pdf Yes Yes Printable Only
Other-English Showcards statement terms glos.pdf Yes Yes Printable Only
Other-English Showcards DI2-Eng.pdf Yes Yes Printable Only
Other-English Showcards DM1-Eng.pdf Yes Yes Printable Only
Other-English Showcards Examples of types of med drs.pdf Yes Yes Printable Only
Other-English Showcards HA1-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF1-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF4-Eng.pdf Yes Yes Printable Only
Other-English Showcards HF7-Eng.pdf Yes Yes Printable Only
Other-English Showcards HH3-Eng.pdf Yes Yes Printable Only
Other-English Showcards HI3 A-D.pdf Yes Yes Printable Only
Other-English Showcards HI3 N.pdf Yes Yes Printable Only
Other-English Showcards HI4-Eng.pdf Yes Yes Printable Only
Other-English Showcards HIMC2-Eng.pdf Yes Yes Printable Only
Other-English Showcards HIT2-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA1-Eng.pdf Yes Yes Printable Only
Other-English Showcards IA4-Eng.pdf Yes Yes Printable Only
Other-English Showcards IU-Eng.pdf Yes Yes Printable Only
Other-English Showcards KN4-Eng.pdf Yes Yes Printable Only
Other-English Showcards Language Identification Card.pdf Yes Yes Printable Only
Other-English Showcards KN9-Eng.pdf Yes Yes Printable Only
Other-English Showcards MP3-Eng.pdf Yes Yes Printable Only
Other-English Showcards OM1-Eng.pdf Yes Yes Printable Only
Other-English Showcards OM4-Eng.pdf Yes Yes Printable Only
Other-English Showcards PD1-Eng.pdf Yes Yes Printable Only
Other-English Showcards pronunc guide.pdf Yes Yes Printable Only
Other-English Showcards RX1-Eng.pdf Yes Yes Printable Only
Other-English Showcards SC1-Eng.pdf Yes Yes Printable Only
Other-English Showcards SC4-Eng.pdf Yes Yes Printable Only
Other-English Showcards ST2-Eng.pdf Yes Yes Printable Only
Other-English Showcards US1-Eng.pdf Yes Yes Printable Only
Other-Section By Section AC_04.01.0001.pdf Yes Yes Printable Only
Other-Section By Section CE_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section DI_04.01.0002.pdf Yes Yes Printable Only
Other-Section By Section END_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section EX_03.01.0000.pdf Yes Yes Printable Only
Other-Section By Section HH_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section HIS_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section IP_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section KN_02.01.0003.pdf Yes Yes Printable Only
Other-Section By Section OM_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section PM_06.01.0001.pdf Yes Yes Printable Only
Other-Section By Section RX_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section US_05.01.0001.pdf Yes Yes Printable Only
Other-Section By Section AV_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section CL_07.01.0000.pdf Yes Yes Printable Only
Other-Section By Section DM_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section ENS_07.01.0001.pdf Yes Yes Printable Only
Other-Section By Section HA_05.01.0003.pdf Yes Yes Printable Only
Other-Section By Section HHS_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section IA_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section IRQ_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section MP_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section OP_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section PMS_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section SC_05.01.0003.pdf Yes Yes Printable Only
Other-Section By Section BackgroundVariables_07.01.0000.pdf Yes Yes Printable Only
Other-Section By Section CPS_07.01.0000.pdf Yes Yes Printable Only
Other-Section By Section DU_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section ER_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section HF_05.01.0008.pdf Yes Yes Printable Only
Other-Section By Section HI_05.01.0001.pdf Yes Yes Printable Only
Other-Section By Section IN_05.01.0001.pdf Yes Yes Printable Only
Other-Section By Section IU_05.01.0000.pdf Yes Yes Printable Only
Other-Section By Section NS_07.01.0003.pdf Yes Yes Printable Only
Other-Section By Section PA_04.01.0001.pdf Yes Yes Printable Only
Other-Section By Section PS_04.01.0000.pdf Yes Yes Printable Only
Other-Section By Section ST_05.01.0001.pdf Yes Yes Printable Only
Other-Roster ConditionRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster EventRosterBeginDateRV0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster PMRoster04010000PopUpVars.pdf Yes Yes Printable Only
Other-Roster StatementChargeBundleRoster0501_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster StatementOMEditRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster DMRoster0401_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster PersonRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster ProviderRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster StatementEventEditRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster EventRosterBeginDate0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster PlanRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster SOPRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Roster StatementEventRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-General Specifications ATTACHMENTHI1.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecifications07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsDates07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsQuestionnaireFlow07010001.pdf Yes Yes Printable Only
Other-General Specifications MCBSWVSTechnicalNotes0501_0000.pdf Yes Yes Printable Only
Other-General Specifications ATTACHMENTHI2.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsAttachments07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsDefaultSpecification07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsScreenTypes07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsDatabase07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsGlobalDisplays07010001.pdf Yes Yes Printable Only
Other-General Specifications GeneralSpecificationsSectionOverview07010001.pdf Yes Yes Printable Only
Other-Entire Questionnaire Condensed entire questionnaire condensed.pdf Yes Yes Printable Only

Health Health Care Services

 

16,217 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 48,651 0 1 0 0 48,650
Annual IC Time Burden (Hours) 58,450 0 1,388 0 0 57,062
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
attachment 01 attachment 01.zip 08/25/2010
attachment 02 attachment 02.zip 08/25/2010
attachment 07 attachment 07.zip 08/25/2010
attachment 08 attachment 08.zip 08/25/2010
attachment 10 attachment 10.zip 08/25/2010
Attachment 3 - UPDMCBSBrochure Attachment 3 - UPDMCBSBrochure.pdf 12/17/2010
Attachment 3 - UPDMCBSBrochure Attachment 3 - UPDAttheDoorBrochure2010.pdf 12/17/2010
2010AdvanceLetterwithletterhead 2010AdvanceLetterwithletterhead.pdf 02/06/2012
MCBSConfidentialityAgreement MCBSConfidentialityAgreement.pdf 02/06/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.