CMS-10141 Writing Agents Information Sheet

Medicare Prescription Drug Benefit Program

CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook)2013 Part D.xls

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

OMB: 0938-0964

Document [xlsx]
Download: xlsx | pdf

Overview

Contracting Org Info Sheet
Writing Agents (Plan Paid)
PRA Disclosure Statement


Sheet 1: Contracting Org Info Sheet

Plan Contracted Marketing Organization Information Sheet
Compensation Structure: Unique Identifying number Number of agents covered by compensation structure Marketing Organization Name
Full Name Street Address City State ZIP Code Contact Name Contact Phone # (include area code) Contact Email









































Sheet 2: Writing Agents (Plan Paid)

Writing Agents Information Sheet
Compensation Structure: Unique Identifying number Number of agents covered by compensation structure










Not Applicable

Sheet 3: PRA Disclosure Statement

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0964. The time required to complete this information collection is estimated to average 49 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
File Typeapplication/vnd.ms-excel
AuthorChevell L. Thomas
Last Modified ByDeborah Larwood
File Modified2013-09-13
File Created2008-10-29

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