Information Collection

Creation of Model Notices (Plans) (section 423.120(c)(6))

IC 231340 under ICR 201906-0938-001 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 6a - Instructions for Drug Management Program Notices (version 2).docx	Instruction
CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries Attachment 6b - Initial Notice (version 2).docx	Form and Instruction
CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk St Attachment 6c - 2nd Notice (version 2).docx	Form and Instruction
CMS-10141 Alternate Second Notice Sent to Beneficiary Not Consider Attachment 6d - Alternate 2nd Notice (version 2).docx	Form and Instruction

IC Title:

Creation of Model Notices (Plans) (section 423.120(c)(6))

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.120(c)(6)

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
Instruction			Attachment 6a - Instructions for Drug Management Program Notices (version 2).docx	Yes	Yes	Printable Only
Form and Instruction	CMS-10141	Initial Notice Sent to Potentially At-Risk Beneficiaries	Attachment 6b - Initial Notice (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Second Notice Sent to Beneficiary Designating At-Risk Status	Attachment 6c - 2nd Notice (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Alternate Second Notice Sent to Beneficiary Not Considered At-Risk	Attachment 6d - Alternate 2nd Notice (version 2).docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 212

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	212	212
Annual IC Time Burden (Hours)	636	636
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.