Information Collection

Solicitation for Applications for Medicare Prescription Drug Plan 2015 Contracts

IC 43672 under ICR 201310-0938-010 · OMB 0938-0936.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0936 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10137 Solicitation for Applications for Medicare Prescription Drug Plan 2015 Contracts	Form and Instruction
CMS-10137 Medicare Part D Application for New PACE Organizations ( 2014 Application for New PACE_v.draft 092214_508 Compliant.pdf	Form and Instruction
CMS-10137 Solicitation for Applications for Medicare Prescription 2015 Part D Application_v draft_09222013_508 Compliant.pdf	Form and Instruction
Summ_2015_Part_D_Application_Revisions_30 day.docx Crosswalk	IC Document

IC Title:

Solicitation for Applications for Medicare Prescription Drug Plan 2015 Contracts

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.514 42 CFR 423.440 42 CFR 423.153 42 CFR 423.112 42 CFR 423.120 42 CFR 423.512

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 and Instruction	CMS-10137	Medicare Part D Application for New PACE Organizations (2014 Contract Year)	2014 Application for New PACE_v.draft 092214_508 Compliant.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10137	Solicitation for Applications for Medicare Prescription Drug Plan 2015 Contracts	2015 Part D Application_v draft_09222013_508 Compliant.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 254

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	254	13	241
Annual IC Time Burden (Hours)	2,319	187	2,132
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Summ_2015_Part_D_Application_Revisions_30 day.docx	10/29/2013

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