Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)

Retiree Drug Subsidy Payment Request Instructions (CMS-10170)

OMB: 0938-0977

IC ID: 8838

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Document Name
Document Type
Instruction
Form
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IC Document
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Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.subpart R

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CMS10170 Application Instructions 9_19.docx Yes No Printable Only
Form CMS-10170 Retiree Drug Subsidy Payment CMS10170 RDS Application.docx Yes Yes Fillable Printable

Health Health Care Services

Medicare Retiree Drug Subsidy Program (RDSP), System No. 09-70-0550  70 FR 41035

1,245 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  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 1,245 0 0 -914 0 2,159
Annual IC Time Burden (Hours) 187,995 0 0 -138,014 0 326,009
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10170_RDS Instructions_Track Change CMS10170ApplicationInstructions GDIT edits 2024-05-24.docx 09/18/2024
CMS_10170_RDS Application Track Change CMS10170RDSApplication GDIT edits 2024-05-24.docx 09/18/2024
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