Information Collection

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

IC 8184 under ICR 201603-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-367 -Disclosure Statement -CLEAN 3.25.16.docx	Other-PRA Disclosure Statement
CMS-367 - Instructions to Labelers -CLEAN - updated.3 25 16.docx	Instruction
CORRECTION PRA Disclosure Statement for CMS-367a b and c.docx	Other-Correction to PRA Disclosure S
CMS-367a, CMS-367b Medicaid Drug Program Monthly and Quarterly Drug Reporti DDR Screenshots for CMS-367a_b_c_3.18.16.docx	Form
CMS-367d Supplemental Data Sheet Form367(d)updated.pdf	Form
Form Record Specification Crosswalk - 3 16 16.xlsx Crosswalk - Record Specification	IC Document
Instructions for Labelers Crosswalk 3 16 16.xlsx Crosswalk - Instructions	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
Other-Correction to PRA Disclosure Statement			CORRECTION PRA Disclosure Statement for CMS-367a b and c.docx	No		Printable Only
Form	CMS-367a, CMS-367b, and CMS-367c	Medicaid Drug Program Monthly and Quarterly Drug Reporting	DDR Screenshots for CMS-367a_b_c_3.18.16.docx	Yes	Yes	Fillable Printable
Instruction			CMS-367 - Instructions to Labelers -CLEAN - updated.3 25 16.docx	Yes	No	Printable Only
Other-PRA Disclosure Statement			CMS-367 -Disclosure Statement -CLEAN 3.25.16.docx	No		Printable Only
Form	CMS-367d	Supplemental Data Sheet	Form367(d)updated.pdf	Yes	Yes	Fillable Printable

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	Previously Approved
Annual Number of Responses for this IC	12,810	2,440	10,370
Annual IC Time Burden (Hours)	3,612,603	3,456,260	156,343
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Record Specification	Form Record Specification Crosswalk - 3 16 16.xlsx	03/18/2016
Crosswalk - Instructions	Instructions for Labelers Crosswalk 3 16 16.xlsx	03/18/2016

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