Form CMS-368 State Contact Agency Form

MEDICAID DRUG REBATE PROGRAM
STATE AGENCY CONTACT FORM

STATE AGENCY NAME

TECHNICAL CONTACT – Person responsible for sending and receiving data.
NAME OF CONTACT

FAX
EMAIL ADDRESS

AREA

PHONE NUMBER

EXTENSION

AREA

PHONE NUMBER

EXTENSION

______________________________________________

NAME OF FISCAL AGENT (if applicable)

STREET ADDRESS

CITY

STATE

ZIP CODE

PROGRAM POLICY CONTACT – Person responsible for policy decisions.
NAME OF CONTACT

AREA

PHONE NUMBER

EXTENSION

NAME OF FISCAL AGENT (if applicable)

STREET ADDRESS

CITY
CMS-368 (Exp. 09/30/06)
OMB No. 0938-0582
Rev 3/06

STATE

ZIP CODE

MEDICAID DRUG REBATE PROGRAM

STATE AGENCY CONTACT FORM

STATE AGENCY NAME

REBATE CONTACT – Person responsible for invoice and receipt of rebate payments.
NAME OF CONTACT

AREA

PHONE NUMBER

EXTENSION

NAME OF FISCAL AGENT (if applicable)

STREET ADDRESS

CITY

CMS-368 (Exp. 09/30/03)
OMB No. 0938-0582

STATE

ZIP CODE