Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10146(SP) Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP) Form and Instruction
Denial_Notice_Instructions_03022016_CLEAN.pdf Instruction
Crosswalk- Denial Notice CLEAN 08242016.pdf Other-Crosswalk - Form and Instructi
CMS-10146(SP) Notice of Denial of Medicare Prescription Drug Coverage Denial Notice Spanish2013v508.pdf Form and Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Denial Notice_2016_08242016 CLEAN.pdf Form

Information Collection (IC) Details

IC Title:	Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.568(d) 42 CFR 423.580 42 CFR 423.582 42 CFR 423.568(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10146(SP)	Notice of Denial of Medicare Prescription Drug Coverage	Denial Notice Spanish2013v508.pdf	Yes	No	Fillable Printable
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage (English)	Denial Notice_2016_08242016 CLEAN.pdf	No		Fillable Printable
Instruction			Denial_Notice_Instructions_03022016_CLEAN.pdf	No		Printable Only
Other-Crosswalk - Form and Instruction			Crosswalk- Denial Notice CLEAN 08242016.pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 580	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,902,055	404,126	1,497,929
Annual IC Time Burden (Hours)	475,514	100,987	374,527
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.