Medicare Prescription Drug Coverage and Your Rights (CMS-10147 and 10147SP)

Medicare Prescription Drug Coverage and Your Rights

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0975 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10147SP Medicare Prescription Drug Coverage and Your Rights (CMS-10147 and 10147SP) Form
SP-Spanish Instructions for Pharmacy Notice_06 12 2008.doc Instruction
Pharmacy Notice 10147 rev TRACKED 04 29 2008.doc Other-Form Track Changes
Instructions for Pharmacy Notice_04 29 2008.doc Instruction
CMS-10147SP SUS DERECHOS Y LA COBERTURA DE MEDICARE DE RECETAS M?DIC Supporting Statement 10147 Pharmacy Notice - Part A 04 29 2008.doc Form
CMS-10147 MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS Pharmacy Notice 10147 rev CLEAN 04 29 2008.doc Form

Information Collection (IC) Details

IC Title:	Medicare Prescription Drug Coverage and Your Rights (CMS-10147 and 10147SP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.562(a)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10147SP	SUS DERECHOS Y LA COBERTURA DE MEDICARE DE RECETAS M?DICAS	Supporting Statement 10147 Pharmacy Notice - Part A 04 29 2008.doc	Yes	Yes	Paper Only
Instruction			SP-Spanish Instructions for Pharmacy Notice_06 12 2008.doc	Yes	Yes	Paper Only
Form	CMS-10147	MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS	Pharmacy Notice 10147 rev CLEAN 04 29 2008.doc	Yes	Yes	Paper Only
Other-Form Track Changes			Pharmacy Notice 10147 rev TRACKED 04 29 2008.doc	Yes	Yes	Paper Only
Instruction			Instructions for Pharmacy Notice_04 29 2008.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40,000	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30,000,000	-5,000,000	35,000,000
Annual IC Time Burden (Hours)	500,000	-83,333	583,333
Annual IC Cost Burden (Dollars)	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.