View Information Collection (IC)

View Information Collection (IC)

IC Title:	Creation of Model Notices (Plans) (section 423.120(c)(6))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.120(c)(6)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment 6a - Instructions for Drug Management Program Notices (version 2).docx		Yes	Yes	Printable Only
Form and Instruction	CMS-10141	Initial Notice Sent to Potentially At-Risk Beneficiaries	Attachment 6b - Initial Notice (version 2).docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Second Notice Sent to Beneficiary Designating At-Risk Status	Attachment 6c - 2nd Notice (version 2).docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Alternate Second Notice Sent to Beneficiary Not Considered At-Risk	Attachment 6d - Alternate 2nd Notice (version 2).docx		Yes	Yes	Fillable Fileable

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: 212	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	212	0	0	0	0	212
Annual IC Time Burden (Hours)	636	0	0	0	0	636
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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.