Information Collection

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

IC 8815 under ICR 202409-0938-026 · OMB 0938-0957.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10156 RDS Application Retiree Drug Subsidy (RDS) Application and Instructions (public, private and union sponsors)	Form
CMS10156 Application Instructions.docx	Instruction
CMS10156 Application Instructions.docx	Instruction
CMS-10156 RDS Application CMS10156 RDS Application 9_19.docx	Form
CMS-10156 RDS Application CMS10156 RDS Application 9_19.docx	Form
CMS10156RDSApplication GDIT edits 2024-05-24.docx CMS-10156_RDSApplication_Track Change	IC Document
CMS10156RDSApplication GDIT edits 2024-05-24.docx CMS-10156_RDSApplication_Track Change	IC Document
CMS10156ApplicationInstructions GDIT edits 2024-05-24.docx CMS-10156_Application Instructions_Track Change	IC Document
CMS10156ApplicationInstructions GDIT edits 2024-05-24.docx CMS-10156_Application Instructions_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-10156				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)	79,680	-58,496	138,176
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10156_RDSApplication_Track Change		09/20/2024
CMS-10156_Application Instructions_Track Change		09/20/2024

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

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