HOPDs/ASCs Patient Records

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

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	HOPDs/ASCs 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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,427	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,427	-1,816	10,243
Annual IC Time Burden (Hours)	235,956	-50,848	286,804
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letters		02/13/2026
Letter Invitation for Web Survey		02/13/2026
E-mail Invitation for Web Survey (1st Contact)		02/13/2026
Followup Web Survey Invitation Letter		02/13/2026
Follow up Web Survey Invitation Email		02/23/2024
Web with Mail Followup_Questionnaire Cover Letter		02/23/2024
Prenote Letter for Telephone Only		02/23/2024

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

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