Public Respondents - Retiree Drug Subsidy (RDS) Payment Request and Instructions

Retiree Drug Subsidy Payment Request Instructions (CMS-10170)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0977 can be found here:

Documents and Forms

Document Name Document Type
CMS-10170 Instructions (rev 02-22-2017 by OSORA PRA).pdf Instruction
CMS-10170 Retiree Drug Subsidy Payment CMS-10170 Collection Instrument (rev 02-22-2017 by OSORA PRA).pdf Form

Information Collection (IC) Details

IC Title:	Public Respondents - Retiree Drug Subsidy (RDS) Payment Request and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.subpart R

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10170 Instructions (rev 02-22-2017 by OSORA PRA).pdf		Yes	No	Printable Only
Form	CMS-10170	Retiree Drug Subsidy Payment	CMS-10170 Collection Instrument (rev 02-22-2017 by OSORA PRA).pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Retiree Drug Subsidy Program (RDSP), System No. 09-70-0550	FR Citation: 70 FR 41035

Number of Respondents: 828	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-828	828
Annual IC Time Burden (Hours)	-125,028	125,028
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.