Information Collection

Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)

IC 194738 under ICR 201009-0938-015 · OMB 0938-1113.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1113 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10316 Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316) Form and Instruction
CMS-10316 Medicare Disenrollee Survey (Stand Alone PDP and MAPD) Attachments 1 2 3 and 4_revised09 01 10.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Prescriptio Medicare Advantage Prescription Drug Plan (MA-PD) Disenrollment Reasons Survey (CMS-10316)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.156

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10316	Medicare Disenrollee Survey (Stand Alone PDP and MAPD)	Attachments 1 2 3 and 4_revised09 01 10.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	18,000	18,000
Annual IC Cost Burden (Dollars)	0	0

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.