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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10396 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
7_Visual Aid 2_MAP example.pdf Other-Other-Visual Aid #2 ? Medicati
3_Beneficiary Solicitation Letter [rev 12-11-2015 by OSORA PRA].docx Other-Beneficiary Solicitation Lette
8_Visual Aid 3_PML example.pdf Other-Visual Aid #3 ? Personal Medic
6_Visual Aid 1_Medicare & You_2016_MTM pages only.pdf Other-Visual Aid #1 ? Medicare & You
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 Generic Submission Template - Supporting Statement IC Document

Information Collection (IC) Details

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

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Submission Template - Supporting Statement	2_OMB Request Form Supporting Statement [rev 12-11-2015 by OSORA PRA].docx	12/29/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.