Information Collection

Prescription Drug File

IC 249983 under ICR 202410-0938-023 · OMB 0938-1429.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1429 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10715 (Appendix 4) Prescription Drug File Data Elements(clean)_10.07.24.docx	Other-Data Elements
CMS-10715 (Appendix 4) Prescription Drug File Data Elements(clean)_10.07.24.docx	Other-Data Elements

IC Title:

Prescription Drug File

Agency IC Tracking Number:

CCIIO - 10715

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.212(b)(1)(iii)

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
Other-Data Elements					No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 836

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: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,032	1,869	8,163
Annual IC Time Burden (Hours)	310,992	-698,546	1,009,538
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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