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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.