Information Collection

Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)

IC 8184 under ICR 201404-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-367 Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)	Form
Manufacturer Stand-Alone PRA 0938-0578 -CMS-367_disclosure_statement - CLEAN.doc	Other-PRA Disclosure Statement
Manufacturer Stand-Alone PRA 0938-0578 - CMS-367_Instructions_to_Labelers - CLEAN.docx	Instruction
CMS-367 Medicaid Drug Program Monthly and Quarterly Drug Reporti DDR Screenshots for PRA 3.31.14.docx	Form
CMS-367 Record File Specification CMS-367 for OMB - Record Specification - CLEAN - 4.1.14.docx	Form
Copy of Form Record Specification Crosswalk.xlsx Crosswalk - Record Specification	IC Document
Copy of Instructions for Labelers Crosswalk.xlsx Crosswalk - Instructions for Labelers	IC Document

IC Title:

Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)

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
Form	CMS-367	Medicaid Drug Program Monthly and Quarterly Drug Reporting	DDR Screenshots for PRA 3.31.14.docx	Yes	Yes	Fillable Printable
Other-PRA Disclosure Statement			Manufacturer Stand-Alone PRA 0938-0578 -CMS-367_disclosure_statement - CLEAN.doc	No		Printable Only
Form	CMS-367	Record File Specification	CMS-367 for OMB - Record Specification - CLEAN - 4.1.14.docx	Yes	Yes	Fillable Printable
Instruction			Manufacturer Stand-Alone PRA 0938-0578 - CMS-367_Instructions_to_Labelers - CLEAN.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 610

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
	Approved	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,370	610	320	9,440
Annual IC Time Burden (Hours)	156,343	11,895	4,736	139,712
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Record Specification	Copy of Form Record Specification Crosswalk.xlsx	04/17/2014
Crosswalk - Instructions for Labelers	Copy of Instructions for Labelers Crosswalk.xlsx	04/17/2014

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