Standardized Pharmacy Notice

Standardized Pharmacy Notice: Your Prescription Cannot be Filled (f/k/a Medicare Prescription Drug Coverage and Your Rights) (CMS-10147)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0975 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10147 Standardized Pharmacy Notice Form
Instructions_CMS 10147_02272017_CLEAN.PDF Instruction
CMS-10147 Notice: Medicare Prescription Drug Coverage and Your Rig Pharmacy Notice_CMS 10147_508ed 02_27_2017 CLEAN.pdf Form
CMS-10147 Notice (Spanish): La cobertura de Medicare de las receta Pharmacy Notice_CMS -10147 SPANISH 05 2014 508 FINAL.pdf Form

Information Collection (IC) Details

IC Title:	Standardized Pharmacy Notice	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.562(a)(3) 42 CFR 128(b)(7)(iii) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	CMS-10147	Notice: Medicare Prescription Drug Coverage and Your Rights	Pharmacy Notice_CMS 10147_508ed 02_27_2017 CLEAN.pdf	No	Fillable Printable
Instruction			Instructions_CMS 10147_02272017_CLEAN.PDF	No	Printable Only
Form	CMS-10147	Notice (Spanish): La cobertura de Medicare de las recetas médicas y sus derechos	Pharmacy Notice_CMS -10147 SPANISH 05 2014 508 FINAL.pdf	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 62,000	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	40,100,000	2,479,760	37,620,240
Annual IC Time Burden (Hours)	668,066	41,317	626,749
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.