Information Collection

PBMs

IC 250526 under ICR 202111-0938-012 · OMB 0938-1405.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10788.RxDC Section 204 Reporting Instructions 11-23-21 (final).docx	Instruction
CMS-10788.RxDC Section 204 Reporting Instructions 11-23-21 (final).docx	Instruction

IC Title:

Agency IC Tracking Number:

IC Status:

Obligation to Respond:

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents:

Number of Respondents for Small Entity:

Affected Public:

Percentage of Respondents Reporting Electronically:

table that charts list of burden
		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
Annual IC Time Burden (Hours)
Annual IC Cost Burden (Dollars)

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.