Track Changes - State Contact Form

MEDICAID DRUG REBATE PROGRAM

STATE AGENCY CONTACT FORM

STATE AGENCY NAME

STATE CONTACT – Person must have a valid state email address.  State DDR Contact (SDC)
NAME OF CONTACT EMAIL ADDRESS
	AREA PHONE NUMBER EXTENSION
FAX	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

AREA PHONE NUMBER EXTENSION

FAX

AREA PHONE NUMBER EXTENSION

NAME OF FISCAL AGENT (if applicable)

STREET ADDRESS

CITY

STATE

ZIP CODE

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.