Form CMS-367d Contact Information Sheet

MEDICAID DRUG REBATE AGREEMENT
CONTACT INFORMATION SHEET
Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

LABELER CODE (as assigned by FDA):
LABELER NAME (Corporate name associated with labeler code)

LEGAL CONTACT – Person to contact for legal issues concerning the rebate agreement.

NAME OF CONTACT

PHONE NUMBER (with Area Code):
EXTENSION (if Applicable):
EMAIL ADDRESS: 
NAME OF CORPORATION

STREET ADDRESS
  CITY

STATE

ZIP CODE

INVOICE CONTACT – Person responsible for processing invoice utilization data.

NAME OF CONTACT

PHONE NUMBER (with Area Code):
EXTENSION (if Applicable):
EMAIL ADDRESS: 
NAME OF CORPORATION

  STREET ADDRESS

STATE
ZIP CODE
  CITY

Form CMS-367d (Exp. 02/28/2023) is used by manufacturers when they have a need to update CMS on contact information such as email address, phone
 number, or address, of  their legal, invoice or technical contact for the Medicaid Drug Rebate Program. When needed, the use of Form CMS-367d by
manufacturers is considered mandatory under the authority of Section 1927 of the Social Security Act and the National Drug Rebate Agreement. Under the
Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
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 0938-0578. The time required to complete this information collection is estimated to average 1 hour
per response, including the time to review instructions, 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, Baltimore, Maryland 21244-1850.

MEDICAID DRUG REBATE AGREEMENT
CONTACT INFORMATION SHEET
Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

LABELER CODE (as assigned by FDA):

LABELER NAME (Corporate name associated with labeler code)

TECHNICAL CONTACT – Person responsible for sending and receiving data.

NAME OF CONTACT

PHONE NUMBER (with Area Code):
EXTENSION (if Applicable):
FAX #
EMAIL ADDRESS:
FAX NUMBER (with Area Code):

NAME OF CORPORATION

STREET ADDRESS

  CITY

STATE

ZIP CODE

Form CMS-367d (Exp. 02/28/2023) is used by manufacturers when they have a need to update CMS on contact information such as email address, phone
number, or address, of their legal, invoice or technical contact for the Medicaid Drug Rebate Program. When needed, the use of Form CMS-367d by
manufacturers is considered mandatory under the authority of Section 1927 of the Social Security Act and the National Drug Rebate Agreement. Under the
Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
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 0938-0578. The time required to complete this information collection is estimated to average 1 hour
per response, including the time to review instructions, 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, Baltimore, Maryland 21244-1850.