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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
42 CFR 423
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Other-Compensation Certification
CMS-10141.Attachments 1a-1b (Certifications)-11-07-08.doc
Yes
Yes
Paper Only
Instruction
CMS-10141.Attachments 5a-5c (Instructions)-11-07-08.doc
Yes
Yes
Paper Only
Other-Compensation Structure Submission Form
CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08.doc
Yes
Yes
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,019,723
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
5,289,179
0
-1,875,000
0
0
7,164,179
Annual IC Time Burden (Hours)
1,879,877
0
-937,500
0
0
2,817,377
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CMS-10141
CMS-10141.Attachment 4 (Agent Compensation Information Workbook)-11-07-08.xls
05/06/2009
CMS-10141
CMS-10141.Attachment 3 (Covered Agent Information Sheets Workbook)-11-07-08.xls
05/06/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.