Information Collection

Conducting CMRs with the standardized format and Fulfillment burden

IC 199672 under ICR 201404-0938-004 · OMB 0938-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10396 Conducting CMRs with the standardized format and Fulfillment burden	Form
CMS-10396 Medication Therapy Management Program Standardized Forma 2B_Attachment B_Mockup of Revised Standardized Format_04-01-2014.pdf	Form
2A_Attachment A_Proposed Nonmaterial Revisions_04-01-2014.pdf Crosswalk	IC Document

IC Title:

Conducting CMRs with the standardized format and Fulfillment burden

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.153 (d)(1)(vii)(B)__ 42 CFR 423.153 (d)(1)(vii)(D)__

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-10396	Medication Therapy Management Program Standardized Format	2B_Attachment B_Mockup of Revised Standardized Format_04-01-2014.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 682

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	280,352	-1,594,648	1,875,000
Annual IC Time Burden (Hours)	186,901	-906,849	1,093,750
Annual IC Cost Burden (Dollars)	255,120	-1,451,130	1,706,250

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	2A_Attachment A_Proposed Nonmaterial Revisions_04-01-2014.pdf	04/16/2014

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