Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)

Notice of Denial of Medicare Prescription Drug Coverage

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP) Form
Coverage Denial Notice Instructions 5_27_2010.508.doc Instruction
CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage Coverage Denial Notice 508 compliant 5_27_2010.pdf Form
CMS-10146 Form CMC-10146 SPANISH Form CMS-10146_SPANISH.docx Form
Coverage Denial Notice Instructions TRACKED 5_27_2010.docx Coverage Denial Notice Instructions TRACKED 5_27_2010 IC Document
Coverage Denial Notice TRACKED_06 2010.doc Coverage Denial Notice TRACKED_06 2010 IC Document

Information Collection (IC) Details

IC Title:	Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.568(c) 42 CFR 423.568(d) 42 CFR 423.580 42 CFR 423.582

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10146	Notice of Denial of Medicare Prescription Drug Coverage	Coverage Denial Notice 508 compliant 5_27_2010.pdf	Yes	No	Fillable Printable
Form	CMS-10146	Form CMC-10146 SPANISH	Form CMS-10146_SPANISH.docx	Yes	Yes	Fillable Fileable
Instruction			Coverage Denial Notice Instructions 5_27_2010.508.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 456	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	Previously Approved
Annual Number of Responses for this IC	290,344	290,344
Annual IC Time Burden (Hours)	145,172	145,172
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Coverage Denial Notice Instructions TRACKED 5_27_2010	Coverage Denial Notice Instructions TRACKED 5_27_2010.docx	07/30/2010
Coverage Denial Notice TRACKED_06 2010	Coverage Denial Notice TRACKED_06 2010.doc	07/30/2010

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