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Federal forms, ICRs, and supporting documents

Information Collection

Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)

IC 219253 under ICR 201506-0938-013 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10396
Telephone Interview Script Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)		 Form and Instruction
3_Beneficiary Solicitation Letter [rev 12-11-2015 by OSORA PRA].docx Other-Beneficiary Solicitation Lette
6_Visual Aid 1_Medicare & You_2016_MTM pages only.pdf Other-Visual Aid #1 – Medicare & You
7_Visual Aid 2_MAP example.pdf Other-Visual Aid #2 – Medication Act
8_Visual Aid 3_PML example.pdf Other-Visual Aid #3 – Personal Medic
CMS-10396 Telephone Interview Script
4_Beneficiary Telephone Interview Guide 12022015.docx 		Form and Instruction
2_OMB Request Form Supporting Statement [rev 12-11-2015 by OSORA PRA].docx
Supporting Statement		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Other-Beneficiary Solicitation Letter 3_Beneficiary Solicitation Letter [rev 12-11-2015 by OSORA PRA].docx No   Fillable Fileable Signable
Form and Instruction CMS-10396 Telephone Interview Script 4_Beneficiary Telephone Interview Guide 12022015.docx No   Fillable Printable
Other-Visual Aid #1 – Medicare & You 2016 MTM Pages 6_Visual Aid 1_Medicare & You_2016_MTM pages only.pdf No   Paper Only
Other-Visual Aid #2 – Medication Action Plan Mockup 7_Visual Aid 2_MAP example.pdf No   Paper Only
Other-Visual Aid #3 – Personal Medication List Mockup 8_Visual Aid 3_PML example.pdf No   Paper Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 50 0 50 0 0 0
Annual IC Time Burden (Hours) 17 0 17 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Supporting Statement 2_OMB Request Form Supporting Statement [rev 12-11-2015 by OSORA PRA].docx 12/14/2015
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.