Information Collection

Standardized Pharmacy Notice

IC 37927 under ICR 202410-0938-020 · OMB 0938-0975.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10147 Standardized Pharmacy Notice	Form
Form CMS-10147 Medicare Drug Coverage and Your Rights Standardized Pharmacy Notice	Form
Pharmacy Notice Instructions_.docx	Instruction
Pharmacy Notice Instructions_.docx	Instruction
CMS-10147 Medicare Drug Coverage and Your Rights Pharmacy Notice_CMS 10147.docx	Form
CMS-10147 Medicare Drug Coverage and Your Rights Pharmacy Notice_CMS 10147.docx	Form
Pharmacy Notice_CMS 10147_508ed - redline.docx Pharmacy Notice_Track Change	IC Document
Pharmacy Notice_CMS 10147_508ed - redline.docx Pharmacy Notice_Track Change	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.562(a)(3) 42 CFR 128(b)(7)(iii) (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Form	CMS-10147				No		Fillable Printable
Instruction					No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 72,900

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	55,215,940	5,534,648	49,681,292
Annual IC Time Burden (Hours)	919,898	92,208	827,690
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Pharmacy Notice_Track Change		10/21/2024

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

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