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pdfMEDICAID DRUG REBATE PROGRAM
STATE AGENCY CONTACT FORM
STATE AGENCY NAME
STATE CONTACT – Person must have a valid state email address.
NAME OF CONTACT
State DDR Contact (SDC)
EMAIL ADDRESS
FAX
AREA
PHONE NUMBER
EXTENSION
AREA
PHONE NUMBER
EXTENSION
NAME OF FISCAL AGENT (if applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
TECHNICAL CONTACT – Person responsible for sending and receiving data.
NAME OF CONTACT
EMAIL ADDRESS
FAX
AREA
PHONE NUMBER
EXTENSION
AREA
PHONE NUMBER
EXTENSION
NAME OF FISCAL AGENT (if applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
CMS-368 (Exp. TBD) / OMB No. 0938-0582 / Rev. 1/2017
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 0938-0582. The time required to complete this information collection is estimated to average 30 minutes per response,
including the time to review instructions, search existing data sources, 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,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
MEDICAID DRUG REBATE PROGRAM
STATE AGENCY CONTACT FORM
STATE AGENCY NAME
PROGRAM POLICY CONTACT – Person responsible for policy decisions.
NAME OF CONTACT
EMAIL ADDRESS
AREA
PHONE NUMBER
EXTENSION
NAME OF FISCAL AGENT (if applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
REBATE CONTACT – Person responsible for invoice and receipt of rebate payments.
NAME OF CONTACT
EMAIL ADDRESS
AREA
PHONE NUMBER
EXTENSION
NAME OF FISCAL AGENT (if applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
CMS-368 (Exp. TBD) / OMB No. 0938-0582 / Rev. 1/2017
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 0938-0582. The time required to complete this information collection is estimated to average 30 minutes per response,
including the time to review instructions, search existing data sources, 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,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
| File Type | application/pdf |
| File Title | MEDICAID DRUG REBATE AGREEMENT |
| Author | HCFA Software Control |
| File Modified | 2017-01-25 |
| File Created | 2017-01-25 |