Conducting CMRs with the standardized format and Fulfillment burden

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

OMB: 0938-1154

IC ID: 199672

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Conducting CMRs with the standardized format and Fulfillment burden
No Modified
42 CFR 423.153(d)(1)(vii)(B) 42 CFR 423.153(d)(1)(vii)(D)

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

Health Health Care Services


868 0
Private Sector Businesses or other for-profits
   0 %

  Requested 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 6,992,075 0 4,605,120 0 0 2,386,955
Annual IC Time Burden (Hours) 4,661,616 0 3,070,233 0 0 1,591,383
Annual IC Cost Burden (Dollars) 6,348,804 0 4,128,936 0 0 2,219,868

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