Crosswalk - State Contact Form

Burden Change

Reason for Change

Type of Change

2017 (new version)

2014 (old version)
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To provide each state with the option to submit
state contact information in addition to their
Fiscal Intermediary (FI).

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State Contact Information: (1) State Contact Name, Add
(2) State Contact Phone Number, (3) State Contact
Fax Number, (4) Street Address, (5) City, (6) State,
(7) Zip Code (8) State Contact Email Address
(CMS-368)
Technical Contact Email Address (CMS-368)
Add

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Program Policy Contact Email Address (CMS-368) Add

To provide each State Program Policy Contact
with the option to submit an email address as
part of their reported contact information.

Negligible because not
every labeler will report it.

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Rebate Contact Email Address (CMS-368)

To provide each State Rebate Contact labeler
with the option to submit an email address as
part of their reported contact information.

Negligible because not
every labeler will report it.

Add

Negligible because not
every state will report it.

To provide each State Technical Contact with the Negligible because not
option to submit an email address as part of their every labeler will report it.
reported contact information.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.