Standardized Pharmacy Notice

Standardized Pharmacy Notice: Your Prescription Cannot be Filled (f/k/a Medicare Prescription Drug Coverage and Your Rights)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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
CMS-10147 CMS-10147.Pharnacy Notice - Spanish Version CMS-10147.Spanish Version.pdf Form

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	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
Form	CMS-10147	CMS-10147.Pharnacy Notice - Spanish Version	CMS-10147.Spanish Version.pdf	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	37,087,402	37,087,402
Annual IC Time Burden (Hours)	617,876	617,876
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.