Supplemental Data Sheet (CMS-367d)

Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)

OMB: 0938-0578

IC ID: 222507

Information Collection (IC) Details

View Information Collection (IC)

Supplemental Data Sheet (CMS-367d)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-367d Contact Information Sheet 367d_August 2019_Final.docx.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

743 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,486 0 266 0 0 1,220
Annual IC Time Burden (Hours) 1,486 0 266 0 0 1,220
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-367d - Track Changes 367d_August 2019_Track Changes.docx 12/12/2019
CMS-367d - Crosswalk Form Record Specification Crosswalk_367b_August 2019.xlsx 12/12/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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