Form CMS-367d Contact Information Sheet

MEDICAID DRUG REBATE AGREEMENT

MANUFACTURER CONTACT FORM
Form CMS-367d
Note: If more than one labeler code, complete a separate 367d for each labeler 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

TEL: AREA PHONE NUMBER

EMAIL ADDRESS

EXT.

FAX: AREA PHONE NUMBER

EXT.

NAME OF CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

INVOICE CONTACT – Person responsible for processing invoice utilization data.
NAME OF CONTACT

TEL: AREA PHONE NUMBER

EMAIL ADDRESS

EXT.

FAX: AREA PHONE NUMBER

EXT.

NAME OF CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

Form CMS-367d (Exp. 05/31/2024) 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

MANUFACTURER CONTACT FORM
Form CMS-367d

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

TEL: AREA PHONE NUMBER

EMAIL ADDRESS

EXT.

FAX: AREA PHONE NUMBER

EXT.

NAME OF CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

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

______________________
(signature)

___________________________
(please print name)

Date: _______________________

Form CMS-367d (Exp. 05/31/2024) 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.