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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.