Information Collection

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

IC 37927 under ICR 200809-0938-001 · OMB 0938-0975.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.