Information Collection

Standardized Pharmacy Notice

IC 37927 under ICR 201109-0938-005 · OMB 0938-0975.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0975 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10147 Standardized Pharmacy Notice	Form
Instructions_CMS 2010147_10 2018 2011 Clean.docx	Instruction
CMS-10147 CMS-10147_Pharmacy_Notice_ CMS-10147_Pharmacy_Notice_(clean).pdf	Form

IC Title:

Standardized Pharmacy Notice

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.562(a)(3) 42 CFR 128(b)(7)(iii) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10147	CMS-10147_Pharmacy_Notice_	CMS-10147_Pharmacy_Notice_(clean).pdf		Yes	Yes	Fillable Fileable
Instruction			Instructions_CMS 2010147_10 2018 2011 Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	37,087,402	7,087,402	30,000,000
Annual IC Time Burden (Hours)	617,876	117,876	500,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.