Addendum B track changes document for 2009 renewal 112108

Addendum B track changes document for 2009 renewal 112108.doc

Manufacturer Submission of Average Sales Price (ASP) Data for Medicare Part B Drugs and Biological and Supporting Regulations

Addendum B track changes document for 2009 renewal 112108

OMB: 0938-0921

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CMS-1380-IFC DKH 2/3/2021 2


Addendum B


The Centers for Medicare & Medicaid Services

Average Sales Price Data


Name of Drug or Biological Manufacturer (as “manufacturer” is defined in section 1927(k)(5) of the Social Security Act):



Legal Address:




Manufacturer Contact(s):

Name: Email:


Title: Fax:


Address: Telephone No.:


Name: Email:


Title: Fax:


Address: Telephone No.:


I certify that the reported Average Sales Prices were calculated accurately and that all information and statements made in this submission are true, complete, and current to the best of my knowledge and belief and are made in good faith. I understand that information contained in this submission may be used for Medicare reimbursement

purposes.


Name of CEO, CFO or Authorizing Official:

Title:


__________________________ ____________________

Signature Date


According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0921.

The time required to complete this information collection is estimated to average 37(10 hours) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CMS 10110 approval pending

Expiration date: ___________.


File Typeapplication/msword
File TitleAddendum B
AuthorCMS
Last Modified ByCMS
File Modified2008-11-21
File Created2008-11-21

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