Information Collection

Invitation & Screening

IC 257116 under ICR 202211-0938-013 · OMB 0938-1440.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1440 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10816 Invitation & Screening	Form and Instruction
CMS-10816 Recruitment Script Attachment A - Recruitment Script CMS-10816_508.pdf	Form and Instruction
CMS-10816 Recruitment Script Attachment A - Recruitment Script CMS-10816_508.pdf	Form and Instruction
CMS-10816 Eligibility Screener Questionnaire Attachment C - Eligibility Screener Questionnaire CMS-10816_508.pdf	Form and Instruction
CMS-10816 Eligibility Screener Questionnaire Attachment C - Eligibility Screener Questionnaire_Clean.docx	Form and Instruction
Attachment B - Medicare Part C D Enrollment Form Study Frequently Asked Questions CMS-10816_508.pdf Frequently Asked Questions	IC Document
Attachment B - Medicare Part C D Enrollment Form Study Frequently Asked Questions CMS-10816_508.pdf Frequently Asked Questions	IC Document

IC Title:

Invitation & Screening

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.60 42 CFR 423.32 42 CFR 422.50

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
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug (MARx)â

FR Citation: 83 FR 6591

Number of Respondents: 350

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	350	350
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.