Information Collection

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

IC 187164 under ICR 201008-0938-020 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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 4 (Agent Compensation Information Workbook)-11-07-08.xls CMS-10141	IC Document
CMS-10141.Attachment 3 (Covered Agent Information Sheets Workbook)-11-07-08.xls CMS-10141	IC Document

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:

table that charts list of 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: 1,019,723

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,164,179	4,973,234	27,273	2,163,672
Annual IC Time Burden (Hours)	2,817,377	1,775,489	13,936	1,027,952
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

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