Crosswalk: CMS-367d

2020 (old version)

File Format Header:
MEDICAID DRUG REBATE AGREEMENT
CONTACT INFORMATION SHEET

2021 (new version)

Type of
Change

Reason for Change

Burden Change

File Format Header:
MEDICAID DRUG REBATE AGREEMENT
MANUFACTURER CONTACT FORM
Form CMS-367d

Rev

To align Header with other Medicaid Drug Rebate
Program documentation.

N/A

Manufacturer Signature Block:

Add

For manufacturers to confirm the information
submitted on their 367d is accurate.

N/A

Note: This sheet is to be returned with the signed rebate agreement. If more
Note: If more than one labeler code, complete a separate 367d for each
than one labeler code, attach one sheet for each code.
labeler code.
N/A

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

(signature)
(please print name)
Date: _______________________

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.