Information Collection

Competitive Acquisition Program (CAP) for Medicare Part B Drugs: CAP Physician Election Agreement

IC 8849 under ICR 200806-0938-008 · OMB 0938-0987.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10167 Competitive Acquisition Program (CAP) for Medicare Part B Drugs: CAP Physician Election Agreement	Form and Instruction
cap.osora.cms10167.FINAL.redline.doc	Other-Redline
CMS-10167 Competitive Acquistion Program (CAP) for Medicare Part B cap.osora.cms10167.FINAL.contract.doc	Form and Instruction
cap.osora.cms10167.FINAL.crosswalk.doc cap	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 414.908

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10167	Competitive Acquistion Program (CAP) for Medicare Part B Drugs Cap Physician Election Agreement (Under Section 1847B of the Social Security Act)	cap.osora.cms10167.FINAL.contract.doc		Yes	Yes	Paper Only
Other-Redline			cap.osora.cms10167.FINAL.redline.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,800	-6,200	10,000
Annual IC Time Burden (Hours)	7,600	-12,400	20,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
cap	cap.osora.cms10167.FINAL.crosswalk.doc	06/17/2008

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