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

Comprehensive Addiction and Recovery Act of 2016 (CARA) / Medicare Prescription Drug Benefit Program (CMS-10141)

OMB: 0938-0964

IC ID: 231340

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Creation of Model Notices (Plans) (section 423.120(c)(6))
 
No Modified
 
Mandatory
 
42 CFR 423.120(c)(6)

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

212 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 212 0 0 0 0 212
Annual IC Time Burden (Hours) 636 0 0 0 0 636
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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