Form CMS-368 State Agency Contact Form

MEDICAID DRUG REBATE PROGRAM

STATE AGENCY CONTACT FORM
Form CMS-368
STATE AGENCY NAME
STATE MDRP CONTACT – Person must have a valid state email address.
NAME OF CONTACT

TEL: AREA PHONE NUMBER

EMAIL ADDRESS

EXT.

FAX: AREA PHONE NUMBER

EXT.

AGENCY/OFFICE/CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

STATE TECHNICAL CONTACT – Person responsible for sending and receiving data.
NAME OF CONTACT

TEL: AREA PHONE NUMBER

EMAIL ADDRESS

EXT.

FAX: AREA PHONE NUMBER

EXT.

AGENCY/OFFICE/CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

CMS-368 (Exp. 06/30/2023) / OMB No. 0938-0582
Form CMS-368 is a report of contact for the State to name the individuals involved in the Medicaid Drug Rebate Program (MDRP), and is required only in those instances where a change to the originally submitted data is
necessary. When needed, the use of Form CMS-368 by the State is considered mandatory under the authority of Section 1927 of the Social Security Act. 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
0938-0582. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data sources, 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,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

MEDICAID DRUG REBATE PROGRAM

STATE AGENCY CONTACT FORM
Form CMS-368
STATE AGENCY NAME
STATE POLICY CONTACT – Person responsible for policy decisions.
NAME OF CONTACT

TEL: AREA PHONE NUMBER

EMAIL ADDRESS

EXT.

FAX: AREA PHONE NUMBER

EXT.

AGENCY/OFFICE/CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

STATE REBATE CONTACT – Person responsible for invoice and receipt of rebate payments.
NAME OF CONTACT

TEL: AREA PHONE NUMBER

EMAIL ADDRESS

EXT.

FAX: AREA PHONE NUMBER

EXT.

AGENCY/OFFICE/CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

Verification by the State
I certify that the contact information provided on this form is accurate.
By:

______________________
(signature)

___________________________
(please print name)

Date: _______________________
CMS-368 (Exp. 06/30/2023) / OMB No. 0938-0582
Form CMS-368 is a report of contact for the State to name the individuals involved in the Medicaid Drug Rebate Program (MDRP), and is required only in those instances where a change to the originally submitted data is
necessary. When needed, the use of Form CMS-368 by the State is considered mandatory under the authority of Section 1927 of the Social Security Act. 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
0938-0582. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data sources, 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,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.