Form CMS-367d Supplemental Data Sheet

MEDICAID DRUG REBATE AGREEMENT
ENCLOSURE B (PAGE 1 OF 2)
SUPPLEMENTAL DATA SHEET
LABELER CODE (as assigned by FDA)

LABELER NAME (Corporate name associated with labeler code)

LEGAL CONTACT – Person to contact for legal issues concerning the rebate agreement
NAME OF CONTACT
AREA

PHONE NUMBER

EXTENSION

EMAIL ADDRESS:

NAME OF CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

INVOICE CONTACT – Person responsible for processing invoice utilization data

NAME OF CONTACT
AREA

PHONE NUMBER

EXTENSION

EMAIL ADDRESS:

NAME OF CORPORATION

STREET ADDRESS

CITY
Note:

STATE

ZIP CODE

This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

CMS-367d (Exp. 03/31/2019), OMB No. 0938-0578 According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0578. The time required to complete this information collection is estimated to average 1 hour per
response, including the time to review instructions, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

MEDICAID DRUG REBATE AGREEMENT
ENCLOSURE B (PAGE 2 OF 2)
SUPPLEMENTAL DATA SHEET
LABELER CODE (as assigned by FDA)

LABELER NAME (Corporate name associated with labeler code)

TECHNICAL CONTACT – Person responsible for sending and receiving data

NAME OF CONTACT
AREA

PHONE NUMBER

EXTENSION

FAX #

EMAIL ADDRESS:

NAME OF CORPORATION

STREET ADDRESS

CITY

Note:

STATE

ZIP CODE

This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

CMS-367d (Exp. 03/31/2019), OMB No. 0938-0578 According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0578. The time required to complete this information collection is estimated to average 1 hour per
response, including the time to review instructions, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.