Information Collection

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

IC 37928 under ICR 201805-0938-001 · OMB 0938-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10146(SP) Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and -10146SP)	Form and Instruction
Denial_Notice_Instructions_rev 05 1 2018 CLEAN.docx	Instruction
CMS-10146(SP) Notice of Denial of Medicare Prescription Drug Coverage SPA_Notice of Denial of Presc Drug Cvg_CMS10146_5.1.2018 CLEAN.docx	Form and Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Denial Notice_rev 05 01 2018 CLEAN.docx	Form

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.580 42 CFR 423.582 42 CFR 423.568(c) 42 CFR 423.568(d)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10146(SP)	Notice of Denial of Medicare Prescription Drug Coverage	SPA_Notice of Denial of Presc Drug Cvg_CMS10146_5.1.2018 CLEAN.docx	Yes	No	Fillable Printable
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage (English)	Denial Notice_rev 05 01 2018 CLEAN.docx	No		Fillable Printable
Instruction			Denial_Notice_Instructions_rev 05 1 2018 CLEAN.docx	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 580

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,902,055	1,902,055
Annual IC Time Burden (Hours)	475,514	475,514
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.