Information Collection

Developing a counteroffer submission per selected drug

IC 261204 under ICR 202307-0938-009 · OMB 0938-1452.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1452 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10849 Developing a counteroffer submission per selected drug	Form and Instruction
CMS-10849 Counteroffer Form clean_Negotiation Offer Exchange ICR Form and Certification_508 FINAL.pdf	Form and Instruction
CMS-10849 Counteroffer Form Final Package_Negotiation Offer Exchange ICR Form and Certification_clean.docx	Form and Instruction

IC Title:

Developing a counteroffer submission per selected drug

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	CMS-10849	Counteroffer Form	Final Package_Negotiation Offer Exchange ICR Form and Certification_clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	2,043	2,043
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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