Information Collection

Rebate Reduction Extension Request Form

IC 268249 under ICR 202405-0938-025 · OMB 0938-1474.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1474 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10858 Rebate Reduction Extension Request Form	Form and Instruction
CMS-10858 Appendix A and BSevere Supply Chain Disruption forms 508_Final clean 30 day notice Appendix A and B_Severe Supply Chain Disruption forms.docx	Form and Instruction
CMS-10858 Appendix A and BSevere Supply Chain Disruption forms 508_Final clean 30 day notice Appendix A and B_Severe Supply Chain Disruption forms.docx	Form and Instruction
CMS-10858 Appendix C and D Likely to be in Shortage forms 508_Final clean 30 day notice Appendix C and D_Likely to be in Shortage forms.docx	Form and Instruction
CMS-10858 Appendix C and D Likely to be in Shortage forms 508_Final clean 30 day notice Appendix C and D_Likely to be in Shortage forms.docx	Form and Instruction
508_Final redline 30 day notice Appendix A and B_Severe Supply Chain Disruption forms (compared to 60-day).docx Redline Appendix A and B	IC Document
508_Final redline 30 day notice Appendix A and B_Severe Supply Chain Disruption forms (compared to 60-day).docx Redline Appendix A and B	IC Document
508_Final redline 30 day notice Appendix C and D_Likely to be in Shortage forms (compared to 60-day).docx Redline Appendix C and D	IC Document
508_Final redline 30 day notice Appendix C and D_Likely to be in Shortage forms (compared to 60-day).docx Redline Appendix C and D	IC Document

IC Title:

Rebate Reduction Extension Request Form

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-10858	Appendix A and BSevere Supply Chain Disruption forms	508_Final clean 30 day notice Appendix A and B_Severe Supply Chain Disruption forms.docx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10858	Appendix C and D Likely to be in Shortage forms	508_Final clean 30 day notice Appendix C and D_Likely to be in Shortage forms.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)	310	310
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Redline Appendix A and B	508_Final redline 30 day notice Appendix A and B_Severe Supply Chain Disruption forms (compared to 60-day).docx	06/04/2024
Redline Appendix C and D	508_Final redline 30 day notice Appendix C and D_Likely to be in Shortage forms (compared to 60-day).docx	06/04/2024

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