Information Collection

Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156)

IC 187541 under ICR 200812-0938-001 · OMB 0938-0957.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0957 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10156 Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156)	Form
CMS10156RDSApplicationChanges.pdf	Other-RDS Application TRK
CMS10156ApplicationInstructions.pdf	Instruction
CMS10156ApplicationInstructionsChanges.pdf	Instruction
CMS-10156 RDS Plan Sponsor Application CMS10156RDSApplication.pdf	Form

IC Title:

Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423 Subpart R

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-10156	RDS Plan Sponsor Application	CMS10156RDSApplication.pdf	Yes	Yes	Paper Only
Other-RDS Application TRK			CMS10156RDSApplicationChanges.pdf	Yes	Yes	Paper Only
Instruction			CMS10156ApplicationInstructions.pdf	Yes	Yes	Paper Only
Instruction			CMS10156ApplicationInstructionsChanges.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Retiree Drug Subsidy Program (RDSP) System No.09-70-0550

FR Citation: 70 FR 41035

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	96,000	96,000
Annual IC Cost Burden (Dollars)	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.