Information Collection

Public - Retiree Drug Subsidy (RDS) Application and Instructions

IC 187541 under ICR 201702-0938-005 · OMB 0938-0957.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0957 can be found here:

Documents and Forms

Document Name Document Type
CMS-10156 Application Instructions (rev 02-22-2017 by OSORA PRA).pdf Instruction
CMS-10156 RDS Application CMS-10156 - Application (rev 02-22-2017 by OSORA PRA).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Public - Retiree Drug Subsidy (RDS) Application and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423 Subpart R

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10156 Application Instructions (rev 02-22-2017 by OSORA PRA).pdf		Yes	No	Printable Only
Form	CMS-10156	RDS Application	CMS-10156 - Application (rev 02-22-2017 by OSORA PRA).pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Retiree Drug Subsidy Program (RDSP) System No.09-70-0550	FR Citation: 70 FR 41035

Number of Respondents: 828	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	828	-672	1,500
Annual IC Time Burden (Hours)	52,992	-43,008	96,000
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.