Information Collection

Hospice Information for Medicare Part D Plans

IC 214736 under ICR 201501-0938-006 · OMB 0938-1269.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1269 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10538 Hospice Information for Medicare Part D Plans	Form and Instruction
CMS-10538 Hospice Information for Medicare Part D Plans Form [rev 01-23-2015 by OSORA PRA].docx	Form and Instruction

IC Title:

Hospice Information for Medicare Part D Plans

Agency IC Tracking Number:

Is this a Common Form? No

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	CMS-10538	Hospice Information for Medicare Part D Plans	Form [rev 01-23-2015 by OSORA PRA].docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 424

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 New Statute
Annual Number of Responses for this IC	376,487	376,487
Annual IC Time Burden (Hours)	31,374	31,374
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.