Information Collection

Annual State Report on CMS VBP Supplemental Rebate Agreements

IC 242409 under ICR 202405-0938-003 · OMB 0938-1385.

Documents and Forms

Documents and forms in this information collection
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 (2024 version 1).pdf	Form
CMS-10722 Annual State Report on CMS VBP Supplemental Rebate Agree CMS-10722 - VBP State Data Worksheet (2024 version 1).pdf	Form
Crosswalk.pdf State Report - Crosswalk	IC Document
Crosswalk.pdf State Report - Crosswalk	IC Document
REDLINE - CMS-10722 - VBP State Data Worksheet (2024 version 1).pdf State Report - Redline	IC Document
REDLINE - CMS-10722 - VBP State Data Worksheet (2024 version 1).pdf State Report - Redline	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	CMS-10722	Annual State Report on CMS VBP Supplemental Rebate Agreements	CMS-10722 - VBP State Data Worksheet (2024 version 1).pdf		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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
Title	Document	Date Uploaded
State Report - Crosswalk	Crosswalk.pdf	05/03/2024
State Report - Redline	REDLINE - CMS-10722 - VBP State Data Worksheet (2024 version 1).pdf	05/03/2024

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