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⚠️ Notice: This information collection may be referencing outdated material.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 -10147SPANISH_10062014_508FINAL.doc.docx 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 128(b)(7)(iii) 42 CFR 423.562(a)(3) (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 -10147SPANISH_10062014_508FINAL.doc.docx	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	Previously Approved
Annual Number of Responses for this IC	40,100,000	40,100,000
Annual IC Time Burden (Hours)	668,066	668,066
Annual IC Cost Burden (Dollars)	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.