Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)

Retiree Drug Subsidy Payment Request Instructions (CMS-10170)

Documents and Forms

Document Name Document Type
CMS10170ApplicationInstructions (002).pdf Instruction
CMS-10170 Retiree Drug Subsidy Payment CMS10170RDSApplication (002).pdf Form

Information Collection (IC) Details

IC Title:	Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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			CMS10170ApplicationInstructions (002).pdf		Yes	No	Printable Only
Form	CMS-10170	Retiree Drug Subsidy Payment	CMS10170RDSApplication (002).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: 1,803	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,803	149	1,654
Annual IC Time Burden (Hours)	115,392	-134,362	249,754
Annual IC Cost Burden (Dollars)	0	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.