Standardized Pharmacy Notice

Medicare Drug Coverage and Your Rights (CMS-10147)

Documents and Forms

Document Name Document Type
Form CMS-10147 Standardized Pharmacy Notice Form
Pharmacy Notice Instructions_.docx Instruction
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

Information Collection (IC) Details

IC Title:	Standardized Pharmacy Notice	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10147	Medicare Drug Coverage and Your Rights	Pharmacy Notice_CMS 10147.docx		No		Fillable Printable
Instruction			Pharmacy Notice Instructions_.docx		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 %

	Requested	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

Title	Document	Date Uploaded
Pharmacy Notice_Track Change	Pharmacy Notice_CMS 10147_508ed - redline.docx	10/21/2024

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