CMS-10450 Mail Survey

CAHPS® Survey for Merit-based Incentive Payment
System (MIPS)

2021 Survey

Note: The final version of the CAHPS for MIPS survey will be posted
to the QPP website or CMS website.

Medicare Provider Experience Survey
Survey Instructions
This survey asks about you and the health care you received in the last six months during visits that
were in-person, by phone or by video call. Answer each question thinking about yourself. Please take
the time to complete this survey. Your answers are very important to us. Please return the survey with
your answers in the enclosed postage-paid envelope to [VENDOR NAME]
Answer all the questions by putting an “X” in the box to the left of your answer, like this:

 Yes
Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. When this happens you will see
an arrow with a note that tells you what question to answer next, like this:
[ If No, Go to #3]. See the example below:
EXAMPLE
1. Do you wear a hearing aid now?
☐ Yes
 No  If No, Go to #3
2. How long have you been wearing a hearing
aid?
☐ Less than one year

3. In the last 6 months, did you have any
headaches?
 Yes
☐ No

☐ 1 to 3 years
☐ More than 3 years
☐ I don’t wear a hearing aid
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381222 (Expiration date: 01/31/2025). The time required to complete this information collection is estimated to average
13.1 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under
the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions
or concerns regarding where to submit your documents, please contact QPP@cms.hhs.gov

Centers for Medicare & Medicaid Services

1

Your Provider
1.

Our records show that you visited the
provider named below in the last 6
months.

Name of provider label goes here
Is that right?
 Yes
 No  If No, go to #24

Your Care From This Provider in
the Last 6 months

These questions ask about your own health
care. Do not include care you got when you
stayed overnight in a hospital. Do not
include the times you went for dental care
visits.
4. In the last 6 months, how many times
did you visit this provider to get care for
yourself?








The questions in this survey will refer to the
provider named in Question 1 as “this
provider.” Please think of that person as you
answer the survey.
2.

Is this the provider you usually see if
you need a check-up, want advice about
a health problem, or get sick or hurt?
 Yes
 No

3.

2

5. In the last 6 months, did you contact this
provider’s office to get an appointment
for an illness, injury or condition that
needed care right away?
 Yes
 No  If No, go to #7

How long have you been going to this
provider?
 Less than 6 months
 At least 6 months but less than
1 year
 At least 1 year but less than 3
years
 At least 3 years but less than 5
years
 5 years or more

None  If None, go to #24
1 time
2
3
4
5 to 9
10 or more times

6.

In the last 6 months, when you
contacted this provider’s office to get
an appointment for care you needed
right away, how often did you get an
appointment as soon as you needed?





Never
Sometimes
Usually
Always

Centers for Medicare & Medicaid Services

7.

In the last 6 months, did you make any
appointments for a check-up or
routine care with this provider?
 Yes
 No  If No, go to #9

8.

In the last 6 months, when you made an
appointment for a check-up or routine
care with this provider, how often did
you get an appointment as soon as you
needed?





9.

Never
Sometimes
Usually
Always

In the last 6 months, did you contact this
provider’s office with a medical
question during regular office hours?
 Yes
 No  If No, go to #11

10. In the last 6 months, when you
contacted this provider’s office during
regular office hours, how often did you
get an answer to your medical question
that same day?





Never
Sometimes
Usually
Always

11.

In the last 6 months, how often did
this provider explain things in a way
that was easy to understand?





12. In the last 6 months, how often did this
provider listen carefully to you?





Never
Sometimes
Usually
Always

13. In the last 6 months, how often
did this provider seem to know the
important information about your
medical history?
 Never
 Sometimes
 Usually
 Always
14. In the last 6 months, how often did this
provider show respect for what you had
to say?





Never
Sometimes
Usually
Always

15. In the last 6 months, how often did this
provider spend enough time with you?





Centers for Medicare & Medicaid Services

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

3

16. In the last 6 months, did this provider
order a blood test, x-ray, or other test
for you?

21.

 Yes
 No  If No, go to #18













17. In the last 6 months, when this provider
ordered a blood test, x-ray, or other test
for you, how often did someone from
this provider’s office follow up to give
you those results?





Never
Sometimes
Usually
Always

18. In the last 6 months, did you and this
provider talk about starting or stopping
a prescription medicine?
 Yes
 No  If No, go to #20

20. In the last 6 months, did you and this
provider talk about how much of your
personal health information you
wanted shared with your family or
friends?
 Yes
 No

4

0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible

Clerks and Receptionists at This
Provider’s Office
22.

19. When you and this provider talked
about starting or stopping a
prescription medicine, did this
provider ask what you thought was
best for you?
 Yes
 No

Using any number from 0 to 10, where
0 is the worst provider possible and 10
is the best provider possible, what
number would you use to rate this
provider?

In the last 6 months, how often were
clerks and receptionists at this
provider’s office as helpful as you
thought they should be?





23.

Never
Sometimes
Usually
Always

In the last 6 months, how often did
clerks and receptionists at this
provider’s office treat you with
courtesy and respect?





Never
Sometimes
Usually
Always

Centers for Medicare & Medicaid Services

Your Care From Specialists in the
Last 6 Months
24. Specialists are doctors like surgeons,
heart doctors, allergy doctors, skin
doctors, and other doctors who
specialize in one area of health care. Is
the provider named in Question 1 of
this survey a specialist?
 Yes If Yes, Please include

 No

this provider as you
answer these questions
about specialists

25. In the last 6 months, did you try to
make any appointments with
specialists?
 Yes
 No  If No, go to #27
26. In the last 6 months, how often was it
easy to get appointments with
specialists?





Never
Sometimes
Usually
Always

All Your Care in the Last 6 Months

These questions ask about all your health
care. Include all the providers you saw for
health care in the last 6 months. Do not
include the times you went for dental care
visits.
27. Your health care team includes all the
doctors, nurses and other people you
see for health care. In the last 6
months, did you and anyone on your
health care team talk about a healthy
diet and healthy eating habits?
 Yes
 No
28. In the last 6 months, did you and
anyone on your health care team talk
about the exercise or physical activity
you get?
 Yes
 No
29. In the last 6 months, did you take any
prescription medicine?
 Yes
 No  If No, go to #32
30. In the last 6 months, how often did
you and anyone on your health care
team talk about all the prescription
medicines you were taking?





Centers for Medicare & Medicaid Services

Never
Sometimes
Usually
Always

5

31. In the last 6 months, did you and anyone
on your health care team talk about how
much your prescription medicines cost?
 Yes
 No
32. In the last 6 months, did anyone on
your health care team ask you if there
was a period of time when you felt sad,
empty, or depressed?
 Yes
 No
33. In the last 6 months, did you and
anyone on your health care team talk
about things in your life that worry you
or cause you stress?
 Yes
 No

About You

34. In general, how would you rate your
overall health?






Excellent
Very good
Good
Fair
Poor

35. In general, how would you rate your
overall mental or emotional health?






Excellent
Very good
Good
Fair
Poor

36. In the last 12 months, have you seen a
doctor or other health provider 3 or
more times for the same condition or
problem?
 Yes
 No  If No, go to #38
37. Is this a condition or problem that has
lasted for at least 3 months?
 Yes
 No
38. Do you now need or take medicine
prescribed by a doctor?
 Yes
 No  If No, go to #40

6

Centers for Medicare & Medicaid Services

39. Is this medicine to treat a condition that
has lasted for at least 3 months?
 Yes
 No
40. In the last 6 months, were any of your
visits for your own health care...
Yes No
a. In person? ........................⃞ ⃞
b. By phone? .......................⃞

⃞

c. By video call?..................⃞

⃞

41. During the last 4 weeks, how much of
the time did your physical health
interfere with your social activities
(like visiting with friends, relatives,
etc.)?






All of the time
Most of the time
Some of the time
A little of the time
None of the time

42. What is your age?











18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 or older

Centers for Medicare & Medicaid Services

43. Are you male or female?
 Male
 Female
44. What is the highest grade or level of
school that you have completed?
 8th grade or less
 Some high school, but did not
graduate
 High school graduate or GED
 Some college or 2-year degree
 4-year college graduate
 More than 4-year college
degree
45. How well do you speak English?





Very well
Well
Not well
Not at all

46. Do you speak a language other than
English at home?
 Yes
 No  If No, go to #48
47. What is the language you speak at
home?
 Spanish
 Chinese
 Korean
 Russian
 Vietnamese
 Some other language

Please print: ___________________

7

48. Are you deaf or do you have serious
difficulty hearing?
 Yes
 No
49. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
 Yes
 No
50. Because of a physical, mental, or
emotional condition, do you have
serious difficulty concentrating,
remembering, or making decisions?
 Yes
 No
51. Do you have serious difficulty walking
or climbing stairs?
 Yes
 No
52. Do you have difficulty dressing or
bathing?
 Yes
 No
53. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such as
visiting a doctor’s office or shopping?
 Yes
 No

8

54.

Do you ever use the internet at home?
 Yes
 No

55. Are you of Hispanic, Latino, or Spanish
origin?
 Yes, Hispanic, Latino, or
Spanish
 No, not Hispanic, Latino, or
Spanish  If No, go to #57
56. Which group best describes you?
 Mexican, Mexican American,
Chicano  Go to #57
 Puerto Rican  Go to #57
 Cuban  Go to #57
 Another Hispanic, Latino, or
Spanish origin  Go to #57
57. What is your race? Mark one or more.
 White
 Black or African American
 American Indian or Alaska
Native
 Asian Indian
 Chinese
 Filipino
 Japanese
 Korean
 Vietnamese
 Other Asian
 Native Hawaiian
 Guamanian or Chamorro
 Samoan
 Other Pacific Islander

Centers for Medicare & Medicaid Services

58. Did someone help you complete this
survey?
 Yes
 No  Thank you.
Please return the completed
survey in the postage-paid
envelope.

59. How did that person help you? Mark one
or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into
my language
 Helped in some other way

Please print: ___________________





Thank you
Please return the completed survey in the postage-paid envelope.
[VENDOR NAME AND ADDRESS HERE]

Centers for Medicare & Medicaid Services

9

Medicare Provider Experience Survey
Alternative survey instructions for use with a scannable form that uses bubbles
rather than boxes for answer choices.
Survey Instructions
This survey asks about you and the health care you received in the last six months months during visits
that were in-person, by phone or by video call. Answer each question thinking about yourself. Please
take the time to complete this survey. Your answers are very important to us. Please return the survey
with your answers in the enclosed postage-paid envelope to [VENDOR NAME].
Answer all the questions by filling in the circle to the left of your answer, like this:

• Yes

Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. When this happens you will see
an arrow with a note that tells you what question to answer next, like this:
[ If No, Go to #3]. See the example below:
EXAMPLE
1.

Do you wear a hearing aid now?

o

Yes

• No  If No, Go to #3
2.

In the last 6 months, did you have any
headaches?

• Yes

How long have you been wearing a
hearing aid?

o
o
o
o

3.

o

No

Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing aid
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1222 (Expiration date: 01/31/2022). The time required to complete this
information collection is estimated to average 13.1 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please
do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining
to the information collection burden approved under the associated OMB control number listed on this
10

Centers for Medicare & Medicaid Services

form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where
to submit your documents, please contact QPP@cms.hhs.gov.

Centers for Medicare & Medicaid Services
1
CAHPS® for MIPS Survey Quality Assurance Guidelines Version 2