Information Collection

Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534

IC 8184 under ICR 201309-0938-031 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
367 disclosure statement.doc	Other-PRA Discolosure Statement
CMS-367 Instructions to Labelers.doc	Instruction
CMS-367a, 367b, 36 CMS Record Specification and Rebate Agreement CMS-367 Record File Layout.doc	Form

IC Title:

Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-PRA Discolosure Statement			367 disclosure statement.doc	Yes	No	Printable Only
Instruction			CMS-367 Instructions to Labelers.doc	Yes	No	Printable Only
Form	CMS-367a, 367b, 367c, and 367d	CMS Record Specification and Rebate Agreement	CMS-367 Record File Layout.doc	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 100

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	14,024	4,424	160	9,440
Annual IC Time Burden (Hours)	775,591	633,511	2,368	139,712
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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