Invitation & Screening

Medicare Part C and Medicare Part D Enrollment Form Interviews (CMS-10816)

OMB: 0938-1440

IC ID: 257116

Information Collection (IC) Details

View Information Collection (IC)

Invitation & Screening
 
No New
 
Voluntary
 
42 CFR 422.60 42 CFR 423.32 42 CFR 422.50

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10816 Recruitment Script Attachment A - Recruitment Script CMS-10816_508.pdf Yes Yes Printable Only
Form and Instruction CMS-10816 Eligibility Screener Questionnaire Attachment C - Eligibility Screener Questionnaire_Clean.docx Yes Yes Printable Only

Health Health Care Services

Medicare Advantage Prescription Drug (MARx)”  83 FR 6591

350 0
   
Individuals or Households
 
   100 %

  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 350 0 0 350 0 0
Annual IC Time Burden (Hours) 30 0 0 30 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Frequently Asked Questions Attachment B - Medicare Part C D Enrollment Form Study Frequently Asked Questions CMS-10816_508.pdf 11/25/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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