Information Collection

Medicaid Payment for Prescription Drugs - Physicians and Hospital Outpatient Departments Collecting and Submitting Drug Identifying Information to State Medicaid Programs (CMS-10215)

IC 181535 under ICR 200708-0938-002 · OMB 0938-1026.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1026 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Bon Secours Health System.tif Bon Secours Health System	IC Document
Charleston Area Medical Center.tif Charleston Area Medical Center	IC Document
Columbus Regional Medical Center.tif Columbus Regional Medical Center	IC Document
Federation of American Hospitals.tif Federation of American Hospitals	IC Document
Gaston Memorial Hospital.tif Gaston Memorial Hospital	IC Document
Grady Health System.tif Grady Health System	IC Document
Hamilton Medical Center.tif Hamilton Medical Center	IC Document
MCG Health System.tif MCG Health System	IC Document
NorthOaks Health System.tif NorthOaks Health System	IC Document
Phoenix Children's Hospital - Robert Meyer.tif Phoenix Children's Hospital - Robert Meyer	IC Document
Phoenix Children's Hospital - Ken Cross.tif Phoenix Children's Hospital - Ken Cross	IC Document
Phoenix Children's Hospital - Larry Smith.tif Phoenix Children's Hospital - Larry Smith	IC Document
Providence Hospital.tif Providence Hospital	IC Document
Rhode Island Hospital.tif Rhode Island Hospital	IC Document
Santa Clara Valley.tif Santa Clara Valley	IC Document
Shands Jacksonville.tif Shands Jacksonville	IC Document
SHNPA.tif SHNPA	IC Document
The Johns Hopkins Hospital DRA Reg Comment.tif The Johns Hopkins Hospital DRA Reg Comment	IC Document
The Johns Hopkins Hospital.tif The Johns Hopkins Hospital	IC Document
The Medical Center of Central Georgia.tif The Medical Center of Central Georgia	IC Document
The Moses H. Cone Memorial Hospital.tif The Moses H	IC Document
University of California, Davis.tif University of California, Davis	IC Document
University of Michigan Hospitals and Health Centers.tif University of Michigan Hospitals and Health Centers	IC Document
Wellstar Douglas Hospital.tif Wellstar Douglas Hospital	IC Document
Women & Infants Hospital of Rhode Island.tif Women & Infants Hospital of Rhode Island	IC Document
pra packet comments and responses melissa june 5 07 (2).doc Response to Comments	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicaid Payment for Prescription Drugs - Physicians and Hospital Outpatient Departments Collecting and Submitting Drug Identifying Information to State Medicaid Programs (CMS-10215)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 447.520

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

Number of Respondents for Small Entity: 20,000

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 45 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,910,400	3,910,400
Annual IC Time Burden (Hours)	15,837	15,837
Annual IC Cost Burden (Dollars)	336,294	336,294

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Bon Secours Health System	Bon Secours Health System.tif	07/19/2007
Charleston Area Medical Center	Charleston Area Medical Center.tif	07/19/2007
Columbus Regional Medical Center	Columbus Regional Medical Center.tif	07/19/2007
Federation of American Hospitals	Federation of American Hospitals.tif	07/19/2007
Gaston Memorial Hospital	Gaston Memorial Hospital.tif	07/19/2007
Grady Health System	Grady Health System.tif	07/19/2007
Hamilton Medical Center	Hamilton Medical Center.tif	07/19/2007
MCG Health System	MCG Health System.tif	07/19/2007
NorthOaks Health System	NorthOaks Health System.tif	07/19/2007
Phoenix Children's Hospital - Robert Meyer	Phoenix Children's Hospital - Robert Meyer.tif	07/19/2007
Phoenix Children's Hospital - Ken Cross	Phoenix Children's Hospital - Ken Cross.tif	07/19/2007
Phoenix Children's Hospital - Larry Smith	Phoenix Children's Hospital - Larry Smith.tif	07/19/2007
Providence Hospital	Providence Hospital.tif	07/19/2007
Rhode Island Hospital	Rhode Island Hospital.tif	07/19/2007
Santa Clara Valley	Santa Clara Valley.tif	07/19/2007
Shands Jacksonville	Shands Jacksonville.tif	07/19/2007
SHNPA	SHNPA.tif	07/19/2007
The Johns Hopkins Hospital DRA Reg Comment	The Johns Hopkins Hospital DRA Reg Comment.tif	07/19/2007
The Johns Hopkins Hospital	The Johns Hopkins Hospital.tif	07/19/2007
The Medical Center of Central Georgia	The Medical Center of Central Georgia.tif	07/19/2007
The Moses H	The Moses H. Cone Memorial Hospital.tif	07/19/2007
University of California, Davis	University of California, Davis.tif	07/19/2007
University of Michigan Hospitals and Health Centers	University of Michigan Hospitals and Health Centers.tif	07/19/2007
Wellstar Douglas Hospital	Wellstar Douglas Hospital.tif	07/19/2007
Women & Infants Hospital of Rhode Island	Women & Infants Hospital of Rhode Island.tif	07/19/2007
Response to Comments	pra packet comments and responses melissa june 5 07 (2).doc	07/19/2007

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