Information Collection

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)

IC 214725 under ICR 201412-0938-006 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

View Information Collection (IC)

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:

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	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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.