Information Collection

Drug Formulary Changes Template

IC 235621 under ICR 201904-0938-005 · OMB 0938-1365.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10696 Drug Formulary Changes Template	Form and Instruction
CMS-10696 Drug Formulary Change Template CMS-10696 - Drug Formulary Changes Template.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

10696

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10696	Drug Formulary Change Template	CMS-10696 - Drug Formulary Changes Template.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 520

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
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	520	520
Annual IC Time Burden (Hours)	20,800	20,800
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.