Information Collection

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

IC 8838 under ICR 202409-0938-020 · OMB 0938-0977.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10170 Retiree Drug Subsidy Payment Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)	Form
CMS10170 Application Instructions 9_19.docx	Instruction
CMS10170 Application Instructions 9_19.docx	Instruction
CMS-10170 Retiree Drug Subsidy Payment CMS10170 RDS Application.docx	Form
CMS-10170 Retiree Drug Subsidy Payment CMS10170 RDS Application.docx	Form
CMS10170ApplicationInstructions GDIT edits 2024-05-24.docx CMS-10170_RDS Instructions_Track Change	IC Document
CMS10170ApplicationInstructions GDIT edits 2024-05-24.docx CMS-10170_RDS Instructions_Track Change	IC Document
CMS10170RDSApplication GDIT edits 2024-05-24.docx CMS_10170_RDS Application Track Change	IC Document
CMS10170RDSApplication GDIT edits 2024-05-24.docx CMS_10170_RDS Application Track Change	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.subpart R

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
Instruction					Yes	No	Printable Only
Form	CMS-10170				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

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

FR Citation: 70 FR 41035

Number of Respondents: 1,245

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,245	-914	2,159
Annual IC Time Burden (Hours)	187,995	-138,014	326,009
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10170_RDS Instructions_Track Change		09/18/2024
CMS_10170_RDS Application Track Change		09/18/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].