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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:
Modified
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
2023_Cost_Payment_Summary_CPS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Demographic Income
2023_Demographics_Income_DIQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
End Questionaire
2023_End_END.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Enumeration Summary
2022_Enumeration_Summary_ENS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Mobility of Beneficiaries
2022_Mobility_MBQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Post Statement Cost
2022_Post_Statement_Cost_PSQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Access to Care
2022_Access_to_Care_ACQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Chronic Pain
2024_Chronic_Pain_CPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Dental, Vision, and Hearing Care Utilization
2023_Den_Vis_Hear_Care_Utl_DVH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Drug Coverage
2022_Drug_Coverage_RXQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Emergency Utilization
2022_Emergency_Utilization_ERQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health Insurance
2024_Health_Insurance_HIQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Home Health
2022_Home_Health_Util_HHQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Housing_Characteristics
2022_Housing_Charcs_HAQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Income_and_ Assets
2022_Income_and_Assets_IAQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Inpatient Utilization
2022_Inpatient_Utilization_IPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Institutional Utilization
2022_Institutional_Util_IUQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Introduction
2023_Introduction_INQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Medical Provider Utilzation
2022_Medical_Provider_Util_MPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Nicotine Alcohol
2022_Nicotine_Alcohol_Use_NAQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
No Statement Cost
2023_No_Statement_Cost_NSQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Other Medical Expense
2022_Other_Medical_Expense_OMQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Outpatient Utilization
2022_Outpatient_Util_OPQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Prescribed Medicine Utilization
2022_Prescribed_Med_Util_PMQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Satisfaction Care
2023_Satisfaction_with_Care_SCQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Statement Cost Series
2023_Statement_Cost_Series_STQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Beneficiary Knowledge
2023_Beneficiary_Knowledge_KNQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Preventive Care
2023_Preventive_Care_PVQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Usual Source of Care
2024_Usual_Source_Of_Care_USQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Showcards and Reference Cards
2024CommShowcards508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Facility Showcards
2023FacilityShowcards.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Facility Screener
Fac2022_Facility_Screener_FACSCREEN.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Residence History Missing Data
Fac2022_Residence_Missing_RHM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Residence History
Fac2022_Residence_History_RH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Use of Health Services
Fac2023_Health_Status_HS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Background_Questionnaire
Fac2023_Background_BQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Background_Questionnaire MIssing Data
Fac2022_Background_Missing_BQM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Expenditures
Fac2022_Expenditures_EX.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Questionaire Missing Data
Fac2022_Facility_Missing_FQM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Questionaire
Fac2022_Facility_Quex_FQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health_Insurance
Fac2023_Health_Insurance_IN.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health_Status
Fac2023_Health_Status_HS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Cognitive Measures
2023_Cognitive_Measures_CMQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Health Status and Functioning Questionnaire Specification
2024_Health_Status_HFQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Physical_Measures
2023_Physical_Measures_PXQ.pdf
Yes
Yes
Fillable Fileable
Form
P-0015A
COVID-19 Questionnaire Specifications
Fac2024_COVID_19_Bene_CV.pdf
Yes
Yes
Fillable Fileable
Form
P-0015A
COVID-19 Facility-Level Supplement
2024_COVID_19_CVQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Use of Health Services Section Specifications
Fac2023_Use_Health_Services_US.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Telemedicine Questionnaire
2023_Telemedicine_TLQ.pdf
Yes
Yes
Fillable Fileable
Form
CMS-P-0015A
Physical Measures Frequently Asked Questions (FAQ) Sheet
ComPhysicalMeasuresFAQ.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:
35,015
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
35,015
0
-983
0
0
35,998
Annual IC Time Burden (Hours)
34,368
0
-12,145
0
0
46,513
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.