Information Collection

Medicare Prescription Drug Benefit Program (Plan)

IC 187165 under ICR 200901-0938-003 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10141.Attachment 4 (Agent Compensation Information Workbook)-11-07-08.xls	Other-Agent Compensation Information
CMS-10141.Attachment 3 (Covered Agent Information Sheets Workbook)-11-07-08.xls	Other-Covered Agent Information
CMS-10141.Attachments 1a-1b (Certifications)-11-07-08.doc	Other-Certification
CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08.doc	Other-Structure Submission
CMS-10141.Attachments 5a-5c (Instructions)-11-07-08.doc	Instruction

IC Title:

Medicare Prescription Drug Benefit Program (Plan)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.2274(d)

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Agent Compensation Information	CMS-10141.Attachment 4 (Agent Compensation Information Workbook)-11-07-08.xls	Yes	Yes	Paper Only
Other-Covered Agent Information	CMS-10141.Attachment 3 (Covered Agent Information Sheets Workbook)-11-07-08.xls	Yes	Yes	Paper Only
Other-Certification	CMS-10141.Attachments 1a-1b (Certifications)-11-07-08.doc	Yes	No	Paper Only
Other-Structure Submission	CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08.doc	Yes	Yes	Paper Only
Instruction	CMS-10141.Attachments 5a-5c (Instructions)-11-07-08.doc	Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 87

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	Program Change Due to New Statute
Annual Number of Responses for this IC	87	87
Annual IC Time Burden (Hours)	4,263	4,263
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.