Information Collection

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

IC 187164 under ICR 201506-0938-007 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10141 Writing Agents Information Sheet Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)	Form
Form CMS-10141 Compensation Structure for Writing Agents by Contract/PBP Number Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)	Form
CMS-10141.Attachments 1a-1b (Certifications)-11-07-08.doc	Other-Compensation Certification
CMS-10141.Attachments 5a-5c (Instructions)-11-07-08.doc	Instruction
CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08.doc	Other-Compensation Structure Submiss
CMS-10141 Writing Agents Information Sheet CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook)2013 Part D.xls	Form
CMS-10141 Compensation Structure for Writing Agents by Contract/PB CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook)-2013 Part D PRA.xls	Form

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Compensation Certification		Yes	Yes	Paper Only
Instruction		Yes	Yes	Paper Only
Other-Compensation Structure Submission Form		Yes	Yes	Paper Only
Form	CMS-10141	Yes	Yes	Fillable Printable
Form	CMS-10141	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 86,378

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	Previously Approved
Annual Number of Responses for this IC	35,484,743	35,484,743
Annual IC Time Burden (Hours)	4,661,013	4,661,013
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.

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