Information Collection

Private Sector -- Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170)

IC 8838 under ICR 201311-0938-026 · OMB 0938-0977.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0977 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS10170InstructionstoCollectionInstrument[1].pdf	Instruction
CMS-10170 Retiree Drug Subsidy Payment CMS10170CollectionInstrument[1].pdf	Form

IC Title:

Private Sector -- Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.subpart R

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
Instruction			CMS10170InstructionstoCollectionInstrument[1].pdf		Yes	No	Printable Only
Form	CMS-10170	Retiree Drug Subsidy Payment	CMS10170CollectionInstrument[1].pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Retiree Drug Subsidy Program (RDSP), System No. 09-70-0550

FR Citation: 70 FR 41035

Number of Respondents: 3,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	453,000	453,000
Annual IC Cost Burden (Dollars)	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.