Information Collection

Annual State Report on CMS VBP Supplemental Rebate Agreements

IC 242409 under ICR 202106-0938-006 · OMB 0938-1385.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1385 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10722 Annual State Report on CMS VBP Supplemental Rebate Agreements	Form
CMS-10722 Annual State Report on CMS VBP Supplemental Rebate Agree CMS-10722 - VBP State Data Worksheet CMS-2482-F (06-11-2021).xlsx	Form
CMS-10722 Annual State Report on CMS VBP Supplemental Rebate Agree CMS-10722 - VBP State Data Worksheet CMS-2482-F (06-11-2021).xlsx	Form
Crosswalk 10722 5-19-2021.xlsx Crosswalk (CMS-2482-P vs CMS-2482-F)	IC Document
Crosswalk 10722 5-19-2021.xlsx Crosswalk (CMS-2482-P vs CMS-2482-F)	IC Document

IC Title:

Annual State Report on CMS VBP Supplemental Rebate Agreements

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	CMS-10722	Annual State Report on CMS VBP Supplemental Rebate Agreements	CMS-10722 - VBP State Data Worksheet CMS-2482-F (06-11-2021).xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	306	306
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk (CMS-2482-P vs CMS-2482-F)	Crosswalk 10722 5-19-2021.xlsx	06/11/2021

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