Information Collection

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

IC 188650 under ICR 200904-0938-001 · OMB 0938-0977.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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)

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:

table that charts list of 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 %

table that charts list of burden
	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

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.