Conducting CMRs with the standardized format and Fulfillment burden

Medication Therapy Management Program – Standardized Format (CMS-10396)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1154 can be found here:

Documents and Forms

Document Name Document Type
MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf Instruction
MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf Instruction

Information Collection (IC) Details

IC Title:	Conducting CMRs with the standardized format and Fulfillment burden	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.153(d)(1)(vii)(B) 42 CFR 423.153(d)(1)(vii)(D)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			MTM Program Standardized Format (English Spanish)(v10.18.2021).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 868	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,992,075	4,605,120	2,386,955
Annual IC Time Burden (Hours)	4,661,616	3,070,233	1,591,383
Annual IC Cost Burden (Dollars)	6,348,804	4,128,936	2,219,868

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.