Information Collection

Programming the standardized format

IC 199670 under ICR 201110-0938-002 · OMB 0938-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1154 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10396 Programming the standardized format Form and Instruction
CMS-10396 MEDICATION THERAPY MANAGEMENT PROGRAM STANDARDIZED FORMA CMS-10396_MTMP_Standardized_Format.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Programming the standardized format	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.153 (d)(1)(vii)(B)__ 42 CFR 423.153 (d)(1)(vii)(D)__

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10396	MEDICATION THERAPY MANAGEMENT PROGRAM STANDARDIZED FORMAT	CMS-10396_MTMP_Standardized_Format.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 673	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
Annual Number of Responses for this IC	673	673
Annual IC Time Burden (Hours)	80,760	80,760
Annual IC Cost Burden (Dollars)	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.