View Information Collection (IC)

View Information Collection (IC)

IC Title:	Solicitation for Applications for Medicare Prescription Drug Plan 2017 Contracts	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.120 42 CFR 423.440 42 CFR 423.153 42 CFR 423.514 42 CFR 423.112 42 CFR 423.512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10137	Medicare Part D Application for New PACE Organizations 2016 Contract Year	2016 PACE Part D Application 30 Day PRA.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10137	Solicitation for Applications for Medicare Prescription Drug Plan 2017 Contracts	2017 Part D Application_30day_PRA.pdf		Yes	Yes	Fillable Printable

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: 230	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	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	230	0	0	-9	0	239
Annual IC Time Burden (Hours)	2,109	0	0	-84	0	2,193
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Part_D_Summ_2017_Application_Revisions_technical__substantive_v30_day.docx	09/30/2015

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