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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.