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⚠️ Notice: This information collection may be referencing outdated material.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: Modified

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-Payment Set-Up (CMS-10170)	CMS10170CollectionInstrument.pdf	Yes	Yes	Paper Only
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

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: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,000	-3,000	6,000
Annual IC Time Burden (Hours)	453,000	231,000	222,000
Annual IC Cost Burden (Dollars)	0	-68,136,000	68,136,000

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.