Information Collection

Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)

IC 187164 under ICR 200905-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Compensation Certification	CMS-10141.Attachments 1a-1b (Certifications)-11-07-08.doc	Yes	Yes	Paper Only
Instruction	CMS-10141.Attachments 5a-5c (Instructions)-11-07-08.doc	Yes	Yes	Paper Only
Other-Compensation Structure Submission Form	CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,018,762	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,163,672	-26,828	2,190,500
Annual IC Time Burden (Hours)	1,027,952	63,682	964,270
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10141	CMS-10141.Attachment 3 (Covered Agent Information Sheets Workbook)-11-07-08.xls	05/06/2009
CMS-10141	CMS-10141.Attachment 4 (Agent Compensation Information Workbook)-11-07-08.xls	05/06/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.