View Information Collection (IC)

View Information Collection (IC)

IC Title:	Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.32(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10718	Enrollment Form	'NEW' CY 2021 MODEL MA PDP Indiv Enrollment Request Form_Final.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: Medicare Advantage Prescription Drug (MARx) System	FR Citation: 83 FR 6591

Number of Respondents: 60	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 %

	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	536,717	0	536,717	0	0	0
Annual IC Time Burden (Hours)	1,268,824	0	1,268,824	0	0	0
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.