Quarterly Utilization Report (CMS-R-144)

Medicaid Drug Rebate Program Forms (CMS-368 and CMS-R-144)

OMB: 0938-0582

IC ID: 212418

Information Collection (IC) Details

View Information Collection (IC)

Quarterly Utilization Report (CMS-R-144)
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-R-144 Medicaid Drug Rebate Invoice CMS R-144_2014.pdf Yes Yes Fillable Printable
Instruction Data Definitions_2014.pdf Yes No Printable Only
Instruction Invoice Instructions_2014.pdf Yes No Printable Only
Instruction Record Layout_2014.pdf Yes Yes Printable Only
Other-PRA Disclosure Statement CMS-R-144 Disclosure Statement_2014.doc Yes No Printable Only

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 224 0 0 224 0 0
Annual IC Time Burden (Hours) 12,096 0 0 12,096 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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