CMS-10638 New Technology Tracking Form

Centers for Medicare & Medicaid Services

Center for Medicare Management

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Tracking Form for Applicants for New Technology Add-on Payments under the Acute Inpatient Prospective Payment System (IPPS) for Federal Fiscal Year (FY) 2018

Note: The information provided on this tracking form will be made publicly available.

1. Technology Name:

2. Manufacturer Name:

3. Trade Brand of Technology:

4. Brief Description of Service, Device or Drug:

For the complete application requirements, please see the instructions at http://www.cms.hhs.gov/AcuteInpatientPPS/08_newtech.asp#TopOfPage)--.

Note: The information provided on this tracking form will be made publicly available.