Medicare Prescription Drug Benefit Program (Plan)

Medicare Prescription Drug Benefit Program

OMB: 0938-0964

IC ID: 187165

Documents and Forms
Document Name
Document Type
Other-Agent Compensation Information
Other-Covered Agent Information
Other-Certification
Other-Structure Submission
Instruction
Information Collection (IC) Details

View Information Collection (IC)

Medicare Prescription Drug Benefit Program (Plan)
 
No New
 
Mandatory
 
42 CFR 423.2274(d)

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

87 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 87 87 0 0 0 0
Annual IC Time Burden (Hours) 4,263 4,263 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
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