Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Document Name Document Type
Form Beneficiary Teleph Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6) Form and Instruction
3_Beneficiary solicitation letter_MTMP_Improvements [ rev 01-23-2014 by OSORA PRA].docx Other-Medicare Beneficiary Mailed So
Beneficiary Teleph CMS-10396 4_Telephone interview guide_MTMP_Improvements [ rev 01-23-2015 by OSORA PRA].docx Form and Instruction
2_Fast Track Request Form_MTMP_Improvements.docx Supporting Statement IC Document
7_CMS MTM Program Standardized Format (v07.15.2014).pdf Currently Approved Instrument IC Document
5_Visual Aid #1_MTMP_Improvements.docx Currently Approved Instrument - Visual Aid 1 IC Document
6_Visual Aid #2_MTMP_Improvements.docx Currently Approved Instrument - Visual Aid 2 IC Document

Information Collection (IC) Details

IC Title:	Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Beneficiary Telephone Interview Script	CMS-10396	4_Telephone interview guide_MTMP_Improvements [ rev 01-23-2015 by OSORA PRA].docx		No		Printable Only
Other-Medicare Beneficiary Mailed Solicitation Letter			3_Beneficiary solicitation letter_MTMP_Improvements [ rev 01-23-2014 by OSORA PRA].docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	2_Fast Track Request Form_MTMP_Improvements.docx	01/23/2015
Currently Approved Instrument	7_CMS MTM Program Standardized Format (v07.15.2014).pdf	01/23/2015
Currently Approved Instrument - Visual Aid 1	5_Visual Aid #1_MTMP_Improvements.docx	01/23/2015
Currently Approved Instrument - Visual Aid 2	6_Visual Aid #2_MTMP_Improvements.docx	01/23/2015

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