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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-P-0015A
Cost Payment Summary
2018_Cost_Payment_Summary_CPS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Demographic Income
2018_Demographics_Income_DIQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
End Questionaire
2018_End_END.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Enumeration Summary
2018_Enumeration_Summary_ENS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Home Health Summary
2018_Home_Health_Summary_HHS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
nterviewer Remarks
2018_Interviewer_Remarks_IRQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Mobility of Beneficiaries
2018_Mobility_MBQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Post Statement Cost
2018_Post_Statement_Cost_PSQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Access to Care
2019_Access_to_Care_ACQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Chronic Pain
2019_Chronic_Pain_CPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Dental, Vision, and Hearing Care Utilization
2019_Dental_Vision_Hearing_Util_DVH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Drug Coverage
2019_Drug_Coverage_RXQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Emergency Utilization
2019_Emergency_Utilization_ERQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health Insurance
2019_Health_Insurance_HIQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Home Health
2019_Home_Health_Util_HHQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Housing_Characteristics
2019_Housing_Charcs_HAQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Income_and_ Assets
2019_Income_and_ Assets_IAQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Inpatient Utilization
2019_Inpatient_Utilization_IPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Institutional Utilization
2019_Institutional_Util_IUQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Introduction
2019_Introduction_INQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Medical Provider Utilzation
2019_Medical_Provider_Util_MPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Nicotine Alcohol
2019_Nicotine_Alcohol_Use_NAQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
No Statement Cost
2019_No_Statement_Cost_NSQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Other Medical Expense
2019_Other_Medical_Expenses_OMQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Outpatient Utilization
2019_Outpatient_Util_OPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Prescribed Medicine Utilization
2019_Prescribed_Med_Util_PMQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Satisfaction Care
2019_Satisfacation_Care_SCQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Statement Cost Series
2019_Statement_Cost_Series_STQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Beneficiary Knowledge
2020_Beneficiary_Knowledge_KNQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Preventive Care
2020_Preventive_Care_PVQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Usual Source of Care
2020_Usual_Source_Of_Care_USQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Showcards and Reference Cards
2020CommShowcards.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Facility Showcards
2018FacilityShowcards508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Facility Screener
Fac2018_Facility_Screener_FACSCREEN.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Residence History Missing Data
Fac2018_Residence_History_Missing_Data_RHM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Residence History
Fac2018_Residence_History_RH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Use of Health Services
Fac2018_Use_of_Health_Services_US.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Background_Questionnaire
Fac2019_Background_Questionnaire_BQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Background_Questionnaire MIssing Data
Fac2019_Background_Questionnaire_Missing_Data_BQM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Expenditures
Fac2019_Expenditures_EX.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Questionaire Missing Data
Fac2019_Facility_Questionnaire_Missing_Data_FQM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Questionaire
Fac2019_Facility_Questionnaire_FQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health_Insurance
Fac2019_Health_Insurance_IN.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health_Status
Fac2019_Health_Status_HS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health Status
Attachment A - R88 HFQ.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:
35,998
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
35,998
0
0
0
0
35,998
Annual IC Time Burden (Hours)
42,610
0
0
0
0
42,610
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Crosswalk
Summary of Questionnaire Changes_OMB Passback.pdf
08/06/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.