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Federal forms, ICRs, and supporting documents

Information Collection

MPPP Model Notices Programming

IC 267917 under ICR 202405-0938-024 · OMB 0938-1475.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

MPPP Model Notices Programming
 
No New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Exhibit 1_Likely to Benefit Notice_FINAL.docx Yes No Printable Only
Instruction Exhibit 1.2_Likely to Benefit Notice_SPA_FINAL.docx Yes No Printable Only
Instruction Exhibit 1.3_Likely to Benefit Instructions_FINAL.docx Yes No Printable Only
Form and Instruction CMS-10882 Medicare Prescription Payment Plan Participation Request Form Exhibit 2_Election Request_FINAL.docx Yes Yes Fillable Printable
Form and Instruction CMS-10882 Part D Sponsor Notice to Acknowledge Acceptance of Election to the Medicare Prescription Payment Plan Exhibit 3_Notice of Election Approval_FINAL.docx Yes Yes Fillable Printable
Form and Instruction CMS-10882 Part D Sponsor Notice for Failure to Make Payments under the Medicare Prescription Payment Plan Exhibit 4_Notice of Failure to Pay_FINAL.docx Yes Yes Fillable Printable
Form and Instruction CMS-10882 Part D Sponsor Notice for Failure to Make Payments under Medicare Prescription Payment Plan – Notification of Termination of Participation in the Medicare Prescription Payment Plan Exhibit 5_Notice of Involuntary Termination_FINAL.docx Yes Yes Fillable Printable
Form and Instruction CMS-10882 Part D Sponsor Notice of Voluntary Removal from the Medicare Prescription Payment Plan Exhibit 6_Notice of Voluntary Termination_FINAL.docx Yes Yes Fillable Printable

Health Health Care Services

 

1,065 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 1,065 0 0 1,065 0 0
Annual IC Time Burden (Hours) 21,300 0 0 21,300 0 0
Annual IC Cost Burden (Dollars) 8,686,462 0 0 8,686,462 0 0

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.