Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170)

Retiree Drug Subsidy Payment Request Instructions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0977 can be found here:

Documents and Forms

Document Name Document Type
CMS-10170 Collection Instrument Redline New vs. Old.doc Other-TRK Changes
CMS-10170 Instructions to Collection Instrument Old vs New.doc Other-Trk Change
CMS10170InstructionstoCollectionInstrument.pdf Instruction
CMS10170CollectionInstrument.pdf Other-Payment Set-Up (CMS-10170)

Information Collection (IC) Details

IC Title:	Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170)	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:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-TRK Changes	CMS-10170 Collection Instrument Redline New vs. Old.doc	Yes	Yes	Paper Only
Other-Trk Change	CMS-10170 Instructions to Collection Instrument Old vs New.doc	Yes	Yes	Paper Only
Instruction	CMS10170InstructionstoCollectionInstrument.pdf	Yes	Yes	Paper Only
Other-Payment Set-Up (CMS-10170)	CMS10170CollectionInstrument.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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	226,500	226,500
Annual IC Cost Burden (Dollars)	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.