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

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

OMB: 0938-0976

IC ID: 37928

Information Collection (IC) Details

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Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)
 
No Modified
 
Mandatory
 
42 CFR 423.568(d) 42 CFR 423.580 42 CFR 423.582 42 CFR 423.568(c)

Document Type Form No. Form Name Instrument File URL 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_rev 03 01 2017 clean.docx No   Fillable Printable
Instruction Denial_Notice_Instructions_rev 03 03 2017 clean.docx No   Printable Only

Health Health Care Services

 

580 0
   
Private Sector Businesses or other for-profits
 
   0 %

  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 1,902,055 0 0 0 0 1,902,055
Annual IC Time Burden (Hours) 475,514 0 0 0 0 475,514
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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