CMS-367d Medicaid Drug Rebate Agreement

MEDICAID DRUG REBATE AGREEMENT ENCLOSURE B (PAGE 1 OF 2) SUPPLEMENTAL DATA SHEET
LABELER CODE (as assigned by FDA)
LABELER NAME (Corporate name associated with labeler code)
LEGAL CONTACT – Person to contact for legal issues concerning the rebate agreement
NAME OF CONTACT
	AREA PHONE NUMBER EXTENSION
NAME OF CORPORATION
STREET ADDRESS
CITY	STATE		ZIP CODE
INVOICE CONTACT – Person responsible for processing invoice utilization data
NAME OF CONTACT
	AREA PHONE NUMBER EXTENSION
NAME OF CORPORATION
STREET ADDRESS
CITY	STATE		ZIP CODE

Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

CMS-367d (Exp. ) OMB No. 0938-0578

MEDICAID DRUG REBATE AGREEMENT ENCLOSURE B (PAGE 2 OF 2) SUPPLEMENTAL DATA SHEET
LABELER CODE (as assigned by FDA)
LABELER NAME (Corporate name associated with labeler code)
TECHNICAL CONTACT – Person responsible for sending and receiving data
NAME OF CONTACT
	AREA PHONE NUMBER EXTENSION
FAX # ______________________________
EMAIL Address: ______________________________
NAME OF CORPORATION
STREET ADDRESS
CITY	STATE		ZIP CODE

Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

CMS-367d (Exp. )

OMB No. 0938-0578