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
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			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

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	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

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