Form CMS-368 State Agency Contact Form

MEDICAID DRUG REBATE PROGRAM STATE AGENCY CONTACT FORM
STATE AGENCY NAME
TECHNICAL CONTACT – Person responsible for sending and receiving data.
NAME OF CONTACT
	AREA PHONE NUMBER EXTENSION
FAX	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	STATE		ZIP CODE

CMS-368

OMB No. 0938-0582

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	STATE		ZIP CODE

CMS-368

OMB No. 0938-0582