Information Collection

Conducting CMRs with the standardized format and Fulfillment burden

IC 199672 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⚠️ Notice: This information collection may be referencing outdated material.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 Conducting CMRs with the standardized format and Fulfillment burden 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:	Conducting CMRs with the standardized format and Fulfillment burden	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	1,875,000	1,875,000
Annual IC Time Burden (Hours)	1,093,750	1,093,750
Annual IC Cost Burden (Dollars)	1,706,250	1,706,250

Documents for IC

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