Standardized Pharmacy Notice

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

OMB: 0938-0975

IC ID: 37927

Information Collection (IC) Details

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Standardized Pharmacy Notice
 
No Modified
 
Mandatory
 
42 CFR 128(b)(7)(iii) 42 CFR 423.562(a)(3)  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted 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

Health Health Care Services

 

62,000 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 40,100,000 0 0 0 0 40,100,000
Annual IC Time Burden (Hours) 668,066 0 0 0 0 668,066
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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