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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.