Information Collection

Contracted Pharmacy Services Registration and Recertifications

IC 190348 under ICR 201908-0915-001 · OMB 0915-0327.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0327 can be found here:

Documents and Forms

Document Name Document Type
Form 3.1 Contracted Pharmacy Services Registration and Recertifications Form
3.1 Contract Pharmacy Registration.pdf Contract Pharmacy Registration..pdf Form
3.2 Contract Pharmacy Termination.pdf Contract Pharmacy Termination..pdf Form
Contract Pharmacy Registration.docx REDLINE Contract Pharmacy Registration IC Document
Contract Pharmacy Termination.docx REDLINE Contract Pharmacy Termination IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Contracted Pharmacy Services Registration and Recertifications	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3.1	Contract Pharmacy Registration.pdf	Contract Pharmacy Registration..pdf		Yes	Yes	Fillable Fileable
Form	3.2	Contract Pharmacy Termination.pdf	Contract Pharmacy Termination..pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,048	Number of Respondents for Small Entity: 1,200

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	22,528	9,724	12,804
Annual IC Time Burden (Hours)	22,528	19,327	3,201
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
REDLINE Contract Pharmacy Registration	Contract Pharmacy Registration.docx	08/12/2019
REDLINE Contract Pharmacy Termination	Contract Pharmacy Termination.docx	08/12/2019

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