Information Collection

Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)

IC 187164 under ICR 201312-0938-021 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

Documents and Forms

Document Name Document Type
CMS-10141.Attachments 1a-1b (Certifications)-11-07-08.doc Other-Compensation Certification
CMS-10141.Attachments 5a-5c (Instructions)-11-07-08.doc Instruction
CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08.doc Other-Compensation Structure Submiss
CMS-10141 Writing Agents Information Sheet CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook)2013 Part D.xls Form
CMS-10141 Compensation Structure for Writing Agents by Contract/PB CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook)-2013 Part D PRA.xls Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Compensation Certification			CMS-10141.Attachments 1a-1b (Certifications)-11-07-08.doc	Yes	Yes	Paper Only
Instruction			CMS-10141.Attachments 5a-5c (Instructions)-11-07-08.doc	Yes	Yes	Paper Only
Other-Compensation Structure Submission Form			CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08.doc	Yes	Yes	Paper Only
Form	CMS-10141	Writing Agents Information Sheet	CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook)2013 Part D.xls	Yes	Yes	Fillable Printable
Form	CMS-10141	Compensation Structure for Writing Agents by Contract/PBP Number	CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook)-2013 Part D PRA.xls	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 86,378	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	35,484,743	30,195,564	5,289,179
Annual IC Time Burden (Hours)	4,661,013	2,781,136	1,879,877
Annual IC Cost Burden (Dollars)	0	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.