Patient Records

Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) Survey (CMS-10500)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10500 Patient Records Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) Attachment B - CATI Questionnaire [07-31-2018].docx Form
CMS-10500 OAS CAHPS (Web Survey Screenshots) Attachment C - Web Questionnaire [07-31-2018].docx Form and Instruction
OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx Cover Letters IC Document
OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx Letter Invitation for Web Survey IC Document
OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_1st Contact.docx E-mail Invitation for Web Survey (1st Contact) IC Document
OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation for Web Survey (Reminder) IC Document

Information Collection (IC) Details

IC Title:	Patient Records	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10500	OAS CAHPS (Mail Survey)	OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx	No		Fillable Fileable
Form	CMS-10500	OAS CAHPS (Telephone Script)	Attachment B - CATI Questionnaire [07-31-2018].docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Web Survey Screenshots)	Attachment C - Web Questionnaire [07-31-2018].docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,174	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,174	-7,289	9,463
Annual IC Time Burden (Hours)	72,131	-249,611	321,742
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letters	OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx	07/31/2018
Letter Invitation for Web Survey	OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx	07/31/2018
E-mail Invitation for Web Survey (1st Contact)	OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_1st Contact.docx	07/31/2018
E-mail Invitation for Web Survey (Reminder)	OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx	07/31/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.