Form CMS-368 Medicaid Drug Rebate Program, 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

FAX

AREA

PHONE NUMBER

EXTENSION

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

CMS-368
OMB No. 0938-0582

STATE

ZIP CODE

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

CMS-368
OMB No. 0938-0582

STATE

ZIP CODE