Information Collection

Rebate Reduction Extension Request Form

IC 268249 under ICR 202407-0938-012 · OMB 0938-1474.

Documents and Forms

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 Final clean Appendix A and B_Severe Supply Chain Disruption forms.docx Form and Instruction
CMS-10858 Appendix A and BSevere Supply Chain Disruption forms Final clean 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 Final clean 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 Final clean 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Rebate Reduction Extension Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection 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	Final clean 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	Final clean 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 %

	Approved	Previously Approved
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

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.