Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

Documents and Forms

Document Name Document Type
Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146) Form
CMS 10146 Instructions Clean.docx Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Clean CMS 10146 Denial Notice English_508.docx Form
CMS 10146 Denial Notice English Redline.docx Denial Notice Track Change IC Document
CMS 10146 Instructions Redline.docx Denial Notice Instruction Track Change IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.582 42 CFR 423.568(c) 42 CFR 423.568(d) 42 CFR 423.580

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage	Clean CMS 10146 Denial Notice English_508.docx		Yes	No	Fillable Printable
Instruction			CMS 10146 Instructions Clean.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 772	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,962,857	331,129	2,631,728
Annual IC Time Burden (Hours)	740,714	82,782	657,932
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Denial Notice Track Change	CMS 10146 Denial Notice English Redline.docx	09/13/2024
Denial Notice Instruction Track Change	CMS 10146 Instructions Redline.docx	09/13/2024

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