Drug Formulary Changes Template

Information Collection Requirement for Mid-Year Formulary Change Reporting and Notice Requirement (CMS-10696)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Drug Formulary Changes Template	Agency IC Tracking Number:	10696

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 %

	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

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.