Track Change - Dispensing Entity Enrollment Form

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Appendix A: Drug Price Negotiation Program MTF DM Dispensing Entity and Third-Party
Support Entity Enrollment Form
Under the authority in sections 11001 and 11002 of the Inflation Reduction Act of 2022 (P.L. 117169), the Centers for Medicare & Medicaid Services (CMS) is implementing the Medicare Drug Price
Negotiation Program (“the Negotiation Program”), codified in sections 1191 through 1198 of the
Social Security Act (“the Act”). The Act establishes the Negotiation Program to negotiate a
maximum fair price (“MFP”), defined at section 1191(c)(3) of the Act, for certain high expenditure,
single source drugs covered under Medicare Part B and Part D (“selected drugs”). In accordance
with section 1193(a) of the Act, any Primary Manufacturer of a selected drug that continues to
participate in the Negotiation Program and reaches agreement upon an MFP for the selected drug
must provide access to the MFP to MFP-eligible individuals, defined in section 1191(c)(2)(A) of the
Act, and to pharmacies, mail order services, other dispensing entities, providers and suppliers with
respect to such MFP-eligible individuals who are dispensed that selected drug during a price
applicability period.
To facilitate the effectuation of the MFP, CMS will engage a Medicare Transaction Facilitator (MTF).
The MTF system will be comprised of two modules: the MTF Data Module (MTF DM) and the MTF
Payment Module (MTF PM). Primary Manufacturers participating in the Negotiation Program are
required to participate in the MTF DM. Further, CMS intends to proposehas proposed in future
rulemaking a requirement that Part D plan sponsors include in their pharmacy agreements
provisions requiring dispensing entities to be enrolled in the MTF DM. 1 Dispensing entity enrollment
in the MTF DM is needed for necessary operations related to administration of the Negotiation
Program and the Part D program, including creating and making available remittances or ERAs,
maintaining access to the complaints and disputes submission portal, facilitating continued
access to selected drugs that are covered Part D drugs, and ensuring accurate Part D claims
information and payment. As discussed in section 40.4 of the Medicare Drug Price Negotiation
Program: Final Guidance, Implementation of Sections 1191 – 1198 of the Social Security Act for
Initial Price Applicability Year 2027 and Manufacturer Effectuation of the Maximum Fair Price (MFP)
in 2026 and 2027 (“final guidance”), CMS will engage the MTF DM to facilitate the exchange of
certain claim-level data elements and claim-level payment elements for selected drugs. The data
exchange component of the MTF will involve both the transmission of certain claim-level data
elements to the Primary Manufacturer and receipt of claim-level payment elements from the
Primary Manufacturer.
This form is designed to collect the necessary information to process dispensing entity and thirdparty support entity enrollment in the MTF DM. Completing this form within the MTF DM enrollment
module’s user interface will result in dispensing entities securing access to the MTF DM, enabling
these entities to elect their preference for receiving MFP refund payments from the participating
Primary Manufacturers, access reports related to their MFP-eligible claims, and access complaint
Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage
Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive
Care for the Elderly, 89 Fed. Reg. 237 (Dec. 10, 2024), available at
https://www.federalregister.gov/documents/2024/12/10/2024-27939/medicare-and-medicaid-programscontract-year-2026-policy-and-technical-changes-to-the-medicare.
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and dispute functionality. This form will need to be completed only once for each dispensing entity
enrolling in the MTF DM and kept up to date over time.
General information about CMS’ work related to the IRA is available at
https://www.cms.gov/inflation-reduction-act-and-medicare.
The relevant statute pertaining to this ICR can be found at this link:
https://www.congress.gov/117/plaws/publ169/PLAW-117publ169.pdf
The relevant guidance pertaining to this ICR can be found at this link:
https://www.cms.gov/files/document/medicare-drug-price-negotiation-final-guidance-ipay-2027and-manufacturer-effectuation-mfp-2026-2027.pdf
General Instructions
Overview
Dispensing entities submitting Medicare Part D claims from MFP-eligible individuals should
complete only Part I. of this form. Part I requires the completion of the following sections:
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•
•
•
•
•
•

““Dispensing Entity MTF DM User Roles” (Section 1),
“Dispensing Entity Selection” (Section 2),
“Dispensing Entity Identification Information” (Section 32),
“Dispensing Entity Financial Information” (Section 43),
“Dispensing Entity MFP Refund Payment Instructions for Primary Manufacturers Not
Participating in the MTF Payment Module” (Section 4)
“Dispensing Entity Contact Information” (Section 5), and
““Dispensing Entity Certification” (Section 6)

The dispensing entity is responsible for determining and acquiring information necessary to
complete Part I, and for maintaining the completeness and accuracy of the requested information
in the MTF DM as long as the dispensing entity is enrolled in the MTF DM. The dispensing entity
must complete the certification (Section 6) to finalize the submission of this form.
Third-party support entities that contract with a dispensing entity to assist and provide prescriptionrelated, administrative, or intermediary services to a dispensing entity, such as a pharmacy
services administrative organization (PSAO) or reconciliation vendor, should complete only Part II.
Part II requires the completion of the following sections:
•
•
•
•

““Third-Party Support Entity MTF DM User Roles” (Section 1),
“Third-Party Support Entity Identification Information” (Section 2),
“Third-Party Support Entity ContactFinancial Information” (Section 3), and
““Third-Party Support Entity Certification” (Section 5)

“Third-Party Support Entity Financial Information” (Section 4) should also be completed if a thirdparty support entity is contracted designated by a dispensing entity to receive aggregated MFP
refund payments from Primary Manufacturers through the MTF PM on behalf of its dispensing entity
members to then distribute as individual MFP refund payments to its dispensing entity membersits

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behalf. The third-party support entity must complete the certification (Section 5) to finalize the
submission of this form.
Questions about this ICR and dispensing entity and third-party support entity enrollment in the MTF
DM should be sent to [email protected]. For technical assistance related to the enrollment submission
process, questions should be sent to [email protected].
Submission Method
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•

Dispensing entities, and any third-party support entities that intend to play a supporting role
in dispensing entity receipt of MFP refunds, enrolling in the MTF DM should submit
information related to this ICR via [SYSTEM].
Instructions for dispensing entities and third-party support entities to gain access to the
MTF DM to submit information related to this ICR will be available at: [SYSTEM URL].

Additional Instructions
•

The instructions in this section apply to all information submitted by dispensing entities and
third-party support entities.

•

Dispensing entities under common ownership should be enrolled by their parent
organization or chain home office. The parent organization or dispensing entity “chain home
office” (hereinafter “dispensing entity CHO”) is responsible for completing this form on
behalf of all associated locations. If a parent organization is organized into multiple
dispensing entity CHOs (e.g., regionally) with claims reimbursement directed to different
bank accounts for each sub-component, each dispensing entity CHO may enroll in order to
align MFP refund payment with the appropriate payment destination; however, individual
locations (e.g., stores under the CHO) should not enroll independently under these
circumstances. Note that each MTF DM enrollment will be associated with a single payment
destination for MFP refunds.

•

For purposes of this information collection request, all defined terms referenced in this ICR
have their meaning set forth in the final guidance.

•

Questions about the final guidance, including questions about terms defined in the
guidance and used in this ICR, should be sent to [email protected].

•

Response formats are indicated within each question in this ICR.

•

Additional information regarding the Medicare Drug Price Negotiation Program can be found
on CMS’ website here.
Part I: Dispensing Entity Enrollment Questionnaire

Section 1: Dispensing Entity MTF DM User Roles
Section 1 requires the entity completing the dispensing entity enrollment formPart I to assign MTF
DM user roles for any individuals they wish to have user access to the MTF portal. Generally, the
Authorized Signatory Official will have the most capabilities within the MTF while the Staff End User

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will have the least capabilities within the MTF DM. The dispensing entity should determine how
many user roles are appropriate depending on the dispensing entity’s staffing resources and
business practices. Additional information on assigning user roles and user management will be
detailed in upcoming technical instructions.
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•

•

Authorized Signatory Official: An appointed individual of the dispensing entity with authority
to legally bind that organization in agreements, represent the organization in an official
capacity, and act on behalf of an organization. To be eligible, the Authorized Signatory
Official must meet one or more of the following criteria: (1) serve as the Chief Executive
Officer (CEO), where the individual has been duly appointed by the organization’s board or
other governing body; (2) serve as the Chief Financial Officer (CFO), where the individual
has been duly appointed by the organization’s board or other governing body; (3) serve in a
role other than as the CEO or CFO, where the individual has authority that is equivalent to a
CEO or CFO; or (4) serve in a role, where the individual has been granted directly delegated
authority to legally bind the organization on behalf of one of the individuals previously noted
in (1)-(3).
Access Manager: An individual, designated by the Authorized Signatory Official of the
dispensing entity authorized to act on behalf of the organization to view, modify, submit,
and certify the completeness and accuracy of the information on this form and to submit
complaints and disputes in the MTF DM on behalf of the organization.
Staff End User: An individual, designated by the Access Manager of the dispensing entity
authorized to view information in the MTF DM and submit complaints and disputes in the
MTF DM on behalf of the organization.

Instructions
• Complete a row in the table below for every individual for which you wish to assign a user
role for in the MTF DM by selecting the user role from the drop-down menu and providing
the individual’s full name and email address.
Drop-down Menu
[Drop-down Menu]

Response Format – Full Name
Text

Response Format – Email Address
Text

[Drop-down Menu]

Text

Text

[Drop-down Menu]

Text

Text

[Drop-down Menu]

Text

Text

1
2
3

Drop-down Menu Options
Authorized Signatory Official
Access Manager
Staff End User

Section 2: Dispensing Entity SelectionIdentification Information
This section collects basic information about the type of dispensing entity that is enrolling in the
MTF DM. The MTF DM will be designed to facilitate enrollment of a variety of entity types to support

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the implementation of the Negotiation Program. These include a dispensing entity CHO (i.e., an
entity such as a mass merchant or supermarket that provides centralized management and
administrative services from corporate headquarters to pharmacies or dispensing entities under
common ownership) and non-chain dispensing entities, such as independent pharmacies,
independent long-term care pharmacies, Indian Health Service, Tribal, and Urban Indian
pharmacies. Dispensing entities that operate under the same corporate parent should be enrolled
under the dispensing entity CHO designation and enrollment should be completed by their
dispensing entity CHO to ensure that all associated locations are covered under a single,
streamlined submission.
Instructions
•
•

Select the type of entity that is completing the enrollment form.
Please ensure that you select the correct option from the drop-down menu. Choosing the
wrong option may result in incomplete or inaccurate information being collected, which
could extend the time needed to review your information and may require additional followup and other processing and/or payment delays.

Section 2, Question 1. Select from the drop-down menu the type of entity that is completing this
enrollment form.
Section 2Field
Entity Completing Enrollment Form

1
2

Response Format
[Drop-down menu]

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Formatted Table
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Drop-down Menu Options
Dispensing Entity Chain Home Office
Non-Chain Dispensing Entity

Section 2, Question 2. From the options listed below select the industry segment or operating
structure that best characterizes the dispensing entity based upon your response to Question 1. If
more than one operating structure is utilized, select each structure that is applicable to the
dispensing entity NPI. If an operating structure utilized is not listed, select “Other” and explain in
Section 2, Question 3.

Chain Pharmacy

Field

Response Format

☐
☐
☐
☐
☐
☐
☐

Franchise Pharmacy
Independent Pharmacy
Mail Order Pharmacy
Electronic or Online Pharmacy
Long-term Care Pharmacy
Indian/Tribal/Urban Indian (I/T/U) Pharmacy

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Veterans Affairs (VA) Pharmacy

☐

Other Governmental Pharmacy (e.g., pharmacy associated with a
military treatment facility operated by the U.S. Department of Defense
or U.S. Coast Guard clinic)
Other

☐
☐

Section 2, Question 3. If “Other” was selected in response to Question 2, please provide a brief
explanation of the operating structure that best describes your business in the text box below.
Field
Response Format
Explanation of “Other”
Text (200-character limit)
Section 3: Dispensing Entity Identification Information
Section 3 requires identifying information about the dispensing entity, including federally issued
identifying information and demographic, geographic, and relationship information for verification
purposes and to enable enrollment in the MTF DM.
Instructions
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•

•

•

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Dispensing entities are required to complete each table and answer all questions. If the
question is not applicable, please indicate this in the corresponding text field by entering
“Not Applicable.”
Question 1 asks for information that is authorization to use the dispensing entity’s selfreported information to the National Council of Prescription Drug Programs (NCPDP) to
optimize MTF Data Module enrollment procedures. If authorization is not given, the
dispensing entity will be required to manually enter the requested information in Question 2
or upload a roster.
Question 2 asks for identifying information for verification purposes, which can be provided
by completing the table or uploading a roster. , depending on your response to Question 1,
may be prepopulated for you using the NCPDP dataQ Pharmacy Database.
Question 3 provides an opportunity for dispensing entities to self-identify as
havinganticipating material cashflow concerns at the start of the initial price applicability
year due to the shift from payment by the Part D plan sponsor to a combination of Part D
plan sponsor payment plus a potentially lagged MFP refund. Responses to this question are
optional and will be treated as confidential and shared with Primary Manufacturers for
purposes of informing Primary Manufacturer’s development of their MFP Effectuation Plan
only. For example, CMS expects that certain types of dispensing entities—such as sole
proprietor rural and urban pharmacies with high volume of Medicare Part D prescriptions
dispensed; pharmacies who predominantly rely on prescription revenue to maintain
business operations; long-term care pharmacies; 340B covered entities with in-house
pharmacies; and Indian Health Service, Tribal, and Urban Indian (I/T/U) pharmacies—may
have material concerns about cashflow related to the effectuation of MFP.
As stated in section 90.2.1 of the Final Guidance, CMS will make the list of the selfidentified dispensing entities available to Primary Manufacturers in the MTF DM prior to
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Primary Manufacturers’ submission of MFP effectuation plansEffectuation Plans for 2026
and 2027 and will provide updates to reflect changes to the list on an ongoing basis as
otherof dispensing entities enroll in the MTF DM andthat self-identify as having material
cashflow concerns or dispensing entities update their self-identification over time.. CMS
views sharing this list as informational and recognizes a; Each Primary Manufacturer may
establish its own eligibility criteria for determining which dispensing entities are included in
its mitigation approach. Aany such eligibility criteria should, which must be
outlineddescribed in the Primary Manufacturer’s mitigation process in their MFP
Effectuation Plan. The Primary Manufacturer has discretion for dispensing entity inclusion
criteria for any alternative approach ; selecting “Yes” does not guarantee the dispensing
entity will gain access to aany Primary Manufacturer’s mitigation process.
Section 3, Question 1. Please provide the following National Council for Prescription Drug
Programs (NCPDP) identification numbers. If a certain NCPDP identification number is not
applicable, please indicate as such in the corresponding text field.
Section 2, Question 1. Please indicate below if you authorize the MTF to use and rely on the
dispensing entity’s information as reported to NCPDP dataQ Pharmacy Database. Your response
does not affect your ability to designate the dispensing entity as the direct recipient of MFP refund
payments or to designate the third-party support entity listed in the database as the recipient (see
Section 3, Questions 1-1A). Your response will guide how we collect your identifying information
and optimize enrollment procedures in the MTF Data Module. Accordingly, please ensure that your
information in NCPDP dataQ Pharmacy Database is correct and up to date prior to completing this
enrollment form.
Selecting “Yes” means a copy of the most recent information from NCPDP dataQ Pharmacy
Database will be displayed in Question 2 for your verification.
Selecting “No” means the required identifying information will need to be entered manually in
Question 2.
Field
YesNCPDP

“Parent
Organization ID”

Response
Format
Text or
Enter “Not
Applicable”

☐
NCPDP
Text or
“Chain
Enter “Not
Relationship Applicable”
ID” No
☐

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Section 2, Question 1A. If “Yes” was selected in response to Section 2, Question 1, please provide
the information in any one of the following fields to enable CMS to locate and prepopulate
identifying information from the NCPDP dataQ Pharmacy Database. Please note that the NCPDP
Provider ID is relevant to non-chain dispensing entities (i.e., community or independent
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pharmacies). A dropdown menu may be available and prepopulated with information associated
with the user management process.
Field
Section 3

Response Format

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Formatted Table

Legal Business Name OR
Doing Business As (DBA) Name OR
NCPDP Relationship ID (for chains when
NCPDP relationship type = 01) OR
NCPDP Provider ID (for non-chains)

Text
Text
Text or Dropdown Menu

Deleted Cells

Text or Dropdown Menu

Inserted Cells

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Inserted Cells
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together

Section 2, Question 2. A complete and accurate roster of your organization’s location, including
any associated dispensing entity locations. Complete, is required. Based on your response to the
previous questions, the following table may be prepopulated with information from NCPDP dataQ™
Pharmacy Database for verification. Accordingly, please verify the accuracy of the prepopulated
information.

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together
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If you have opted not to authorize use of the NCPDP dataQ™ Pharmacy Database, please complete
the following table, adding rows as applicable, or, if preferred, please upload a roster containing the
requested information. IfIf manually entering information and mailing address and business
address are the same, please indicate that in the text box or document rather than filling out the
same address twice.

Legal
Business
Name

Text or , if

CHO,

prepopulated
by CMSMTF

Doing
Business
As (DBA)
Name

Text or , if

CHO,

prepopulate
d by

CMSMTF

Store
Location
ID
Number,
# (if
applicabl
e.)

Mailing
Address

Business
Address

CHO,

prepopulated
by CMSMTF

NCPDP
“Parent
Organizati
on ID”

NCPDP
“Chain
Relationsh
ip ID”

Pharmacy
National
Provider
Identifier
(NPI)

State
License
Number

Federal
Tax
Identific
ation
Number

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340B Eligible
Entity, or a
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Dispensing
Entity
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contracted to
handle 340B
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claims

6 pt
6 pt
6 pt
6 pt

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Text or , if

CHO,
Text or , if

NCPDP
“Provide
r ID”

Formatted: Font: 6 pt

Text or , if

CHO,

prepopulated
by CMSMTF

prepopulated
by CMS, or

indicate
“Same as
Mailing
Address”M

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Text or , if

CHO,

prepopulate
d by

CMSMTF

Text or , if

CHO,

prepopulated
by CMSMTF

Text or , if

CHO,

prepopulated
by CMSMTF

Text or , if

CHO,

prepopulated
by CMSMTF

Select
from Yes/
NoText or

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Text or prepopulated by MTF

prepopulate
d by MTF

Inserted Cells
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TF

OR

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[DOCUMENT UPLOAD]

Section 32, Question 3A.3. (OPTIONAL) This dispensing entity is self-identifying as a dispensing
entity that anticipates material cashflow concerns for at least one location at the start of the initial

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price applicability year due to the shift from payment by the Part D plan sponsor to a combination
of Part D plan sponsor payment plus a potentially lagged MFP refund.
Field

Response Format

Yes

☐
☐
☐

No
I Prefer Not to Answer

Section 32, Question 3B3A. If “Yes” was selected in response to Question 3A3, please list the
pharmacy NPIs for which the anticipated material cashflow concerns apply, or upload a file that
contains the applicable list of pharmacy NPIs. If “No” was selected in response to Question 3A3,
please do not answer this question and skip to Section 43.
Field
List of applicable NPIs with anticipated material
cashflow concerns

Response Format
Text

OR
[DOCUMENT UPLOAD]

Section 43: Dispensing Entity Financial Information.
Financial information and account details are needed to facilitate the pass through ofin connection
with the MFP refund payment from the Primary Manufacturer to the dispensing entity. This
information may also be necessary for establishing accurate remittance advices or ERAs.
Instructions
•
•

Dispensing entities (and, in Part II of this form, third-party support entities acting on behalf
of dispensing entities) are required to complete the tables and answer all questions.
Dispensing Entity CHO: If the entity completing this section is a Dispensing Entity CHO,
please indicate whether the Dispensing Entity CHO will accept MFP refund payments from
Primary Manufacturers on behalf of all pharmacies under the Dispensing Entity CHO
provided in response to Section 3, Question 2. By selecting “Yes” in response to Question 1,
of this section, the Dispensing Entity CHO authorizes the MTF PM to pass through MFP
refund payments in an aggregated, single amount on a recurring basis from Primary
Manufacturers directly to the payment address or bank account provided. The Dispensing
Entity CHO shall be responsible for disbursing MFP refund payment amounts to its chain
pharmacies as applicable from the single payment passed through by the MTF PM.
o In Question 2 of this section, please indicate whether the organization is contracted
with a third-party support entity. In Question 3 of this section, please indicate the
Dispensing Entity CHO’s preference to receive either a paper check or an electronic
transfer of funds. If electronic transfer of funds is selected, please enter the

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•

•

•

•

required financial information to enable receipt of electronic transfer of funds under
Question 3A. If paper check is selected, please enter the required payment address
information under Question 3B.
o If “No” is selected in response to Question 1 of this section, then further information
will be required regarding each chain pharmacy’s preference for payment via paper
check or electronic transfer of funds under Question 3C of this section.
Non-Chain Dispensing Entity: If the entity completing this section is a “Non-Chain
Dispensing Entity” such as an independent pharmacy, please start by answering Question 2
of this section to indicate whether the organization is contracted with a Third-Party Support
Entity.
o If “Yes” is selected in response to Question 2 of this section, then move forward to
Question 2A and please indicate the services for which the third-party support entity
is contracted to perform related to the MTF on behalf of the dispensing entity. If
more than one third-party support entity is contracted to provide various services to
the dispensing entity, please note all associated third-party support entities using
the form. If a particular MTF-related service is not listed, please select “Other” and
complete the information required under Question 2B of this section. If applicable,
under Questions 2C and 2D, please confirm the third-Party Support Entity that will
receive MFP refund payments and ERAs or remittance advice, respectively, on your
behalf.
o If “No” is selected in response to Question 2 of this section, then skip Question 2A
and Question 2B and move forward to Question 3 of this section.
o Upon completing Question 2 of this section in its entirety, as applicable, please
indicate the organization’s preference to receive either a paper check or an
electronic transfer of funds under Question 3 of this section. If electronic transfer of
funds is selected, please enter the required financial information to enable receipt
of electronic transfer of funds under Question 3A. If paper check is selected, please
enter the required payment address information under Question 3B.
In completing this section, please note the following:
o The financial institution’s name must be the legal business name of that financial
institution.
o The account to which electronic transfer of funds payments is made must bear the
account holder’s name and legal business name.
o Account number should include applicable leading zeros.
Non-Chain Dispensing Entities or Dispensing Entity CHOsentities are responsible for
maintaining the accuracy of information in this section and reporting any changes over
time. Upon any change to the information in this section, the information in this form should
be updated via the MTF DM user interface. Failure to promptly update information may
cause delays or interruptions in processing of MFP refunds.
Under Section 3, Question 41E of this section, please submit a voided check or a letter on
the bank’s letterhead for verification purposes. This helps to ensure the accuracy of
account details and prevents errors in payment processing. Only one type of
documentation is needed. When submitting the banking verification documentation, it
should contain the name on the account (account holder’s name), routing number, account

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•

number, and account type. If submitting bank letterhead, the bank officer’s name and
signature is also required. NOTE: Supporting bank documents must be in the organization’s
legal business name only.
Question 3 concerns tax reporting information. Nonprofit dispensing entities will not
receive an IRS Form 1099.

Section 43, Question 1. If “Dispensing Entity CHO” was selected in responseIrrespective of your
decision to Section 1, Question 1, please indicate whether the Dispensing Entity CHO is authorized
to receive authorize the MTF to rely on your information in the NCPDP dataQ™ Pharmacy Database,
you retain the option to have MFP refund payments from the Primary Manufacturer through the MTF
PMsent either to a third-party support entity listed in that database or to yourself.

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Please confirm whether the dispensing entity is using a third-party support entity for allpurposes of
the MTF:
Field

Response Format

Are you using a third-party support entity to process your MFP
refund payments?

☐ Yes
☐ No

its members

To ensure MFP refund payments are directed appropriately, please confirm where MFP refunds
should be sent (i.e., directly to you or to a third-party support entity you work with).

store locations.

Field

Response Format

Text

Section 13, Question 1, please do not answer this question and skip to Question 21A. Irrespective
of your decision to authorize the MTF to rely on your information in the NCPDP dataQ™ Pharmacy
Database, you retain the option to make ERAs or remittance advice available either to a third-party
support entity listed in that database or to yourself.
Field
YesAre you using a third-party support entity to receive your
ERAs or remittance advice?
No
☐

Response Format
☐ Yes
☐ No

Section 4, Question 2. Please indicate whether
To ensure ERAs or remittance advice are directed appropriately, please confirm the dispensing
entity is contracted withto which ERAs or remittance advice should be made available (i.e., directly
to you or to a third-party support entity. If “Yes,” please ensure that Questions 2A through 2D are
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If “Non-Chain Dispensing Entity” was selected in response to
Name of entity to which MFP refund payments should be sent

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
completed. If “No,” then please skip Questions 2A through 2D move on to Question 3. you work
with).
Field
YesName of entity to which ERAs or remittance advice should
be made available
No
☐

Response Format
Text ☐

Third-party Support
Entity Service

Text

[Service: Drop-down
menu]

1
2
3
4
5

Third-Party
Support
Entity Service
Effective
Dates
Text

Formatted Table

NCPDP Payment
Center ID

NCPDP Remit and
Reconciliation ID

Text or Enter “Not
Applicable”

Text or Enter “Not
Applicable”

Drop-down Menu Options
Central payment(i.e., receive MFP refunds
on behalf of a dispensing entity)
Remittance (i.e., receive ERAs or remittance
advice on behalf of dispensing entity)
Reconciliation (i.e., submit
complaints/disputes on behalf of a
dispensing entity)
Audit assistance (i.e., assist a dispensing
entity or produce records during an
investigation or audit)
Other

Section 4, Question 2B. If “Other” is selected in response to Question 2A, provide a brief
explanation of the service in the text box below.
Field
Explanation of OtherThe dispensing entity and the third-party
support entity Service have mutually agreed that the thirdparty support entity named above will act on the dispensing
entity's behalf in the specified manner.

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Section 4, Question 2A. If “Yes” was selected in response to Question 2, please provide the name
of the dispensing entity’s Please confirm, as applicable, that the dispensing entity and the thirdparty support entity and the MTF-related serviceshave mutually agreed that the third-party support
entity named above is authorized to provide to the dispensing entity for purposes of the MTF. Please
add a new row to enter more than one third-party support act on behalf of the dispensing entity .in
the specified manner:
Third-party
Support Entity

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Response Format
☐ Yes
Text (200-character limit)

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together
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12

PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
Section 4, Question 2C. If applicable, please confirm the third-party support entity that will receive
MFP refunds on the dispensing entity’s behalf by entering the name of the third-party support entity
in the text box below. If not applicable, please enter as such in the text box below.
Field
Response Format
Name of third-party support entity to
which MFP refund payments should be
sent

Text or Enter “Not
Applicable”

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Section 4, Question 2D. If applicable, please confirm the third-party support entity that will receive
ERAs or remittance advice on the dispensing entity’s behalf by entering the name of the third-party
support entity in the text box below. If not applicable, please enter as such in the text box below.
Field
Response Format
Name of third-party support entity to which ERAs or remittance
advice should be made available

Formatted: Font: Bold

Text or Enter “Not
Applicable”

Section 4, Question 3. Select a preference for method of receiving MFP refund payments from
Primary Manufacturers using the MTF Payment Module to effectuate the MFP. After indicating your
payment preference in Question 3 of this section, please answer either Question 3A or Question
3B, depending on your payment preference. Your responses under this question are required to
facilitate the flow of MFP refund payments under a variety of possible circumstances that may arise
during implementation of the Program.
Note: WithSection 3, Question 1B. Questions 1B-1E of this section requests the dispensing
entity’s preference for electronic transfer of funds or check and accompanying details for
completing payment (banking information or address). If you indicated in Question 1 of this section
that MFP refunds should be sent to your third-party support entity (e.g., PSAO), your third-party
support entity will be required to complete Part II of this form to enable the MTF to pass through
MFP refunds to that third-party per your instructions. Their information will override the information
you provide in Questions 1B-1E. Your financial information that you provide in Questions 1B-1E of
this section will be securely stored in the MTF DM and used as needed in case of unforeseen
circumstances that interrupt sending payment to your third-party support entity.
Please note that, with respect to payments passed through the MTF PM, the MTF PM’s transfer of
the Primary Manufacturer’s authorized MFP refund payment to a dispensing entity shall not in any
way indicate or imply that CMS or its MTF Contractors have evaluated or determined that the
amount paid by the Primary Manufacturer is sufficient to make the MFP available to the dispensing
entity and shall not otherwise discharge the Primary Manufacturer’s statutory obligation to make
the MFP available. Neither CMS nor its MTF Contractors will assert independent control over the
disposition of deposited payment amounts or direct payment transfers; instead, the MTF
Contractors will perform a ministerial function at the behest and direction of the participating
Primary Manufacturer with respect to the pass through of the Primary Manufacturer’s funds in the
amounts and to the dispensing entities identified by the Primary Manufacturer in its claim-level
payment elements.
13

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE

Because the MTF PM will only pass payments between Primary Manufacturers and dispensing
entities, under no circumstances will federal funds be used for these transactions or to resolve or
make payment related to disputes that may arise between parties when the MTF PM is utilized,
including with respect to nonpayment or insufficient payment by a particular party. Neither CMS
nor the MTF Contractors will be responsible for funding or paying the refund amounts owed by the
Primary Manufacturer in instances where the Primary Manufacturer does not pay an MFP refund
owed to a dispensing entity, including in cases where the Primary Manufacturer may be unable to
pay (e.g., bankruptcy, insolvency, etc.). Neither CMS nor its MTF Contractors will accrue any
interest on funds held by the MTF PM during the period before the funds are transferred to the
dispensing entity (or returned to the Primary Manufacturer in the event of unclaimed funds). The
MTF PM will serve only as a mechanism to transfer funds of the Primary Manufacturer to dispensing
entities as directed by the Primary Manufacturer in the amounts authorized by the claim-level
payment elements transmitted by the Primary Manufacturer and will not collect funds for any other
use.
Please select your preference for method of receiving MFP refund payments from Primary
Manufacturers using the MTF Payment Module to effectuate the MFP. After indicating your payment
preference in Question 1B of this section, please answer either Question 1C or Question 1D,
depending on your payment preference. Your responses under this question are required to
facilitate the flow of MFP refund payments under a variety of possible circumstances that may arise
during implementation of the Program.
Field
MFP Refund Payment Preference

Response Format
Drop-down menu

Dispensing Entity’s MFP Refund Payment
Preference

Drop-down menu

1
2

Drop-down Menu Options
Electronic transfer of funds (default)
Paper check

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
Section 43, Question 3A1C. If “electronic transfer of funds” was selected in response to Question
3, please complete the table to enable electronic transfer of funds. If “paper check” was selected,
please skip to Question 3C1D.

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For large chains directly receiving MFP refund payments (i.e., not using a third-party support entity),
all MFP refund payments will be directed to the account you provide, below. If your chain has
regional subdivisions or associated store locations that require payments to be deposited into a
separate bank account, those entities must enroll separately, entering their respective bank
accounts.
ERA
Delivery
File
Transfer
Protocol
(FTP)
Address
Text

Bank
Name

Bank
Account
Holder

Bank
Account
Type

Recipient
’s Bank
Account
Number

Recipient’s Bank
Routing Number

Deleted Cells

Text

TextDropdown menu

Text

Text

Deleted Cells

Text

Drop-down Menu Options
1
Checking
2
Savings
Please enter the bank account holder’s information. This information is required in order for the
MTF to validate and transmit payment.
Field
Dispensing Entity Federal
Tax Identification Number
Dispensing Entity NPI
Address Line 1
Address Line 2
City Name
State
Zip

Response Format
Text
Text
Text
Text
Text
Text
Text

Section 43, Question 3B1D. If “paper check” was selected in response to Question 3, please
complete the table to enable receipt of paper checks.

15

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
Field
Payment Address Line 1
RemittancePayment
Address Line 2
City Name
State
Zip Code

Response Format
Text
Text

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Text
Text
Text

Section 4, Question 3B. If “No” was selected in response to Question 1 of this section, please
complete the following table to state the payment preferences for each store that will not be paid
through the Dispensing Entity CHO; or, if preferred, please upload a roster containing the required
information. If “Yes” was selected in response to Question 1 of this section, please skip to Question
4 of this section.
Legal
Business
Name and
Doing
Business
As (DBA)
Name

Pharmacy
National
Provider
Identifier

Prepopulat
ed by CMS
based on
information
derived
from
section 3

Prepopulat
ed by CMS
based on
information
derived
from
section 3

Paper
Check or
electronic
transfer of
funds
(default)

Drop Down

Payment
Address or
ERA
delivery
address

Bank
Name

Bank
Account
Holder

Bank
Account
Type

Recipient’s
Bank
Account
Number

Recipient’s
Bank
Routing
Number

Text

Text or, if
paper
check is
chosen,
option
appears to
user as
“grayed
out”

Text or, if
paper
check is
chosen,
option
appears to
user as
“grayed
out”

Text or, if
paper
check is
chosen,
option
appears
to user as
“grayed
out”

Text or, if
paper check
is chosen,
option
appears to
user as
“grayed out”

Text or, if
paper check
is chosen,
option
appears to
user as
“grayed out”

OR
Section 3, Question 1E. Confirmation of Information Needed for Electronic Transfer of Funds.
To enable electronic transfer of funds, please upload one of the following documents to verify the
banking information provided: either (1) voided check for the account listed, which shows the
account holder’s name, bank account number, and routing number—ensure that the check is
clearly marked as “VOID” across the front; or, (2) letter from bank, printed on official bank
letterhead, that confirms the account holder’s name, account number, and routing number—the
letter must be signed by a representative of the bank and include their contact information for
verification purposes.
[DOCUMENT UPLOAD]

Section 4, Question 4. Confirmation of Financial Information. To verify the banking information
provided, please upload one of the following documents to your submission: either (1) voided
check for the account listed, which shows the account holder’s name, bank account number, and
routing number—ensure that the check is clearly marked as “VOID” across the front; or, (2) letter
from bank, printed on official bank letterhead, that confirms the account holder’s name, account
number, and routing number—the letter must be signed by a representative of the bank and include
their contact information for verification purposes.
16

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE

[DOCUMENT UPLOAD]

Section 3, Question 2. If you indicated that a third-party support entity will receive MFP refunds
and/or ERAs or remittance advice on your behalf in Question 1, please indicate your authorization
for the MTF to use and rely on the third-party support entity’s information as reported to NCPDP
dataQ Pharmacy Database. Your response will guide how we verify dispensing entity/third-party
support entity relationship information. Accordingly, please ensure that your information in NCPDP
dataQ Pharmacy Database is correct and up to date.
Field
Yes, I acknowledge and agree

Response Format

☐

Section 3, Question 3. Please indicate whether your dispensing entity is a nonprofit organization. A
nonprofit organization is generally defined as an entity that is exempt from federal income tax
under Internal Revenue Code Section 501(c). Nonprofit dispensing entities will not receive an IRS
Form 1099.
Field
Is the dispensing entity a nonprofit organization?

Section 4, Question 1. Dispensing Entity Acknowledgment of Information Sharing with Primary
Manufacturers Not Using the MTF Payment Module.
For Primary Manufacturers that are not utilizing the MTF Payment Module, CMS plans to make
available through the MTF DM the bank account information anddispensing entity’s financial
information: preference for electronic transfer of funds or check; bank account information (if
dispensing entity prefers MFP refunds to be sent directly to itself via electronic transfer of funds) or
payment instructions to a third-party support entity; designated destination for ERAs or remittances
for dispensing entities enrolled in the MTF DM; and contact information to support the Primary
Manufacturer’s creation and transmission of an ERA or remittance to the dispensing entity based
on the preferred payment method indicated by the dispensing entity during MTF DM enrollment..
Your information will only be shared with applicable Primary Manufacturers and kept confidential.
Please indicate your acknowledgment and acceptance.
Response Format

☐

Section 4, Question 2. Confirmation of Dispensing Entity MFP Refund Payment Instructions to
a Third-Party Support Entity.

17

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Response Format
☐ Yes
☐ No

Section 4Section 4, Question 5. Primary Manufacturer Payment Outside of the MTF PM.:
Dispensing Entity MFP Refund Payment Instructions for Primary Manufacturers Not
Participating in the MTF Payment Module

Field
Yes, I acknowledge and agree

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
If you indicated in Section 3, Questions 1 and/or 1A that MFP refund payments and/or ERAs or
remittance advice should be sent and made available to a third-party support entity, please confirm
those details by filling in the table, below. Your entry must match your response in Section 3,
Questions 1 and/or 1A. If there is a discrepancy, the system will generate an error and prevent
submission. Your third-party support entity’s information will be obtained through their respective
enrollment form.
Field
Name of third-party support entity to which MFP refund
payments should be sent, as directed by the dispensing
entity
Name of the third-party support entity to which ERAs or
remittance advice should be sent, as directed by the
dispensing entity

Response Format
Text
Text

Section 5: Dispensing Entity Contact Information
Please provide information for two points of contact within the Dispensing Entity. Points of contact
must be able to answer questions about the information submitted on this form. For each point of
contact, two phone numbers are requested, with one being required. The designated points of
contact in this section do not need to match the contacts registered with NCPDP. However, they
should be individuals who are knowledgeable about the contents in this form and able to respond
any inquiries from CMS or the MTF if clarifications or additional information is needed. Accordingly,
please ensure that the designated points of contacts are familiar with the details provided on this
form and can provide timely responses.
Instructions
•
•

Both tables should be completed in their totality, with one exception regarding the number
of phone numbers.
Enter the name and title of a contact person who can answer questions about the
information submitted on this form.

For each pointInstructions
•
•
•

Both tables should be completed in their totality, with one exception regarding the number
of contact, two phone numbers.
Enter the name and title of a contact person who can answer questions about the
information submitted on this form.
are requested, with one being required. If a point of contact only has one phone number
they can be reached at, CMS will accept submissions with only one; if no second phone
number, indicate “Not Available” using in the relevant field.

Section 5, Question 1. Primary Point of Contact
Field

Response Format

Section 5, Question 1. Primary Point of Contact
18

PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
Field
Name

Response Format
Text

First Name

Text

Last Name

Text

Title

Text

Email Address

Text

Phone Number (1)

Text

Phone Number (2) (optional)

Text

Section 45, Question 2. Secondary Point of Contact
Field
Name

Response Format
Text

First Name

Text

Last Name
Title

Text

Email Address

Text

Phone Number (1)

Text

Phone Number (2) (optional)

Text

Section 6. Certification of Dispensing Entity Submission of Sections 1 through 5. Certification
Please finalize your submission by certifying the completeness and accuracy of the information on
the information provided.in sections 1 through 5.
Instruction for Section 6
An individual eligible to certify this submission on behalf of the dispensing entity must be one of the
following: (1) the chief executive officer (CEO) of the organization, (2) the chief financial officer
(CFO) of the organization, (3) an individual other than a CEO or CFO, who has authority equivalent
to a CEO or CFO of the organization, or (4) an individual with the directly delegated authority to
perform the certification on behalf of one of the individuals mentioned in (1) through (3).
Certification:
I hereby certify, to the best of my knowledge, that the information being sent to CMS in this
submission is complete and accurate, and the submission was prepared in good faith and after
reasonable efforts. I reviewed the submission and made a reasonable inquiry regarding its content.
I understand the information contained in this submission is being provided to and will be relied
upon by CMS to facilitate payment of an MFP retrospective refund on MFP-eligible claims of
selected drugs from the Primary Manufacturer to the dispensing entity in accordance with section

19

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
1193(a)(3) of the Social Security Act. I also certify that I will timely notify CMS if I become aware that
any of the information submitted in this form has changed.
Yes [ ]
No [ ]
Field
Name of the Person Responsible for the Submission
Signature
Date

20

Response
Text
Text
MM/DD/YYYY

PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
Part II: Third-Party Support Entity Enrollment Questionnaire
Section 1: MTF DM User Roles
This section is intended to be completed by third-party support entity completing the enrollment
form in order to play a supporting role in dispensing entity receipt of MFP refunds. Only third-party
support entities responsible for central pay and reconciliation services for their contracted
dispensing entities, or those selected by a dispensing entity to receive MFP refunds and/or
ERAs/remittance advice on their behalf, as indicated by the dispensing entity in Part I of this form,
should complete Part II.
Section 1: Third-Party Support Entity MTF DM User Roles
Section 1 requires the entity completing the third-party support entity enrollment form to assign
MTF DM user roles for any individuals they wish to have user access to the MTF portal.
•

•

•

Authorized Signatory Official: An appointed individual of third-party support entity with
authority to legally bind that organization in agreements, represent the organization in an
official capacity, and act on behalf of an organization. To be eligible, the Authorized
Signatory Official must meet one or more of the following criteria: (1) serve as the Chief
Executive Officer (CEO), where the individual has been duly appointed by the organization’s
board or other governing body; (2) serve as the Chief Financial Officer (CFO), where the
individual has been duly appointed by the organization’s board or other governing body; (3)
serve in a role other than as the CEO or CFO, where the individual has authority that is
equivalent to a CEO or CFO; or (4) serve in a role, where the individual has been granted
directly delegated authority to legally bind the organization on behalf of one of the
individuals previously noted in (1)-(3).
Access Manager: An individual, designated by the Authorized Signatory Official of the thirdparty support entity , authorized to act on behalf of the organization to view, modify, submit,
and certify the completeness and accuracy of the information on this form and to submit
complaints and disputes in the MTF DM on behalf of the organization.
Staff End User: An individual, designated by the Access Manager of the third-party support
entity, authorized to view information in the MTF DM and submit complaints and disputes in
the MTF DM on behalf of the organization.

Instructions
• Complete a row in the table below for every individual that you wish to assign a user role for
in the MTF DM by selecting the user role from the drop-down menu and providing the
individual’s full name and email address.
Drop-down Menu
[Drop-down Menu]

Response Format – Full Name
Text

Response Format – Email Address
Text

[Drop-down Menu]

Text

Text

[Drop-down Menu]

Text

Text

[Drop-down Menu]

Text

Text

21

PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE

1
2
3

Drop-down Menu Options
Authorized Signatory Official
Access Manager
Staff End User

Section 2: Third-Party Support Entity Identification Information
Section 2 requires identifying information about the third-party support entity acting on behalf of a
dispensing entity enrolled in the MTF DM, including the third-party support entity’s federally issued
identifying information and demographic, geographic, and relationship information for verification
purposes and to enable enrollment efficiencies in the MTF DM.
Instructions
•

Third-party support entities acting on behalf of dispensing entities enrolled in the MTF DM
should complete each table and answer all questions. If thea question is not applicable,
please indicate as such in the corresponding text field.

•
Section 2, Question 1. Complete the following table for your organization. If mailing address and
business address are the same, please indicate that in the text box rather than filling out the same
address twice.
Legal Business
Name
Text

Doing Business
As (DBA) Name
Text

Mailing
Address
Text

Business
Address
Text

Formatted: Indent: Left: 0.5", No bullets or numbering

Federal Tax
Identification Number
Text

Section 2, Question 2. Please provide the following National Council for Prescription Drug
Programs (NCPDP) identification number(s).) for verification purposes. If a certain NCPDP
identification number is not applicable, please indicate as such in the corresponding text field.
Field
NCPDP “Payment Center ID”
NCPDP “Remit and Reconciliation ID”

Response Format
Text or Enter “Not Applicable”
Text or Enter “Not Applicable”
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Section 2, Question 3. Please indicate the dispensing entity or entities that your organization is
contracted with, list the MTF-related services that your organization is authorized to provide to the
dispensing entity or entities for purposes of the MTF, and the dates from and through which the
contract is effective (“effective dates”) for each service(s)). Please add a new row to enter more
than one dispensing entity. Alternatively, please upload a roster containing the requested
information.
Note: To the extent the third-party support entity is engaged in central payment services and seeks
to receive pass through payment through the MTF PM, by completing this form, the third-party
support entity authorizes the MTF PM to pass through MFP refund payments in an aggregated,
22

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
single amount on a recurring basis from Primary Manufacturers directly to the payment address or
banking account provided. The third-party support entity shall be responsible for disbursement of
MFP refund payment amounts to its members from the single payment passed through by the MTF
PM.
Pharmacy
Legal
Business
Name

Pharmacy
Doing
Business
As (DBA)
Name

Pharmacy
Mailing
Address

Pharmacy
Business
Address

Pharmacy
National
Provider
Identifier
(NPI)

NCPDP
Relationship
ID

Services Contracted and Effective From Date and
Effective Through Date

☐

Central payment (i.e., receive MFP refunds on
behalf of a dispensing entity)

☐

☐ Effective Dates: Text

Remittance (i.e., receive ERAs or remittance
advice on behalf of dispensing entity)

Text

Text

Text

Text

Text

Text

☐

☐ Effective Dates: Text

Reconciliation (i.e., submit complaints/disputes
on behalf of a dispensing entity)

☐

☐ Effective Dates: Text

Audit assistance (i.e., assist a dispensing entity
or produce records during an investigation or audit)

☐

☐ Effective Dates: Text

Other: Text

☐ Effective Dates: Text

OR
[DOCUMENT UPLOAD]

Section 3: Third-Party Support Entity Financial Information
Financial information and account details should be provided by third-party support entities
authorized to receive MFP refund payment from Primary Manufacturers through the MTF PM. This
information may also be necessary for establishing accurate remittance advices or ERAs.
Instructions
• In Question 1 of this section, please indicate your organization’s preference to receive either
a paper check or an electronic transfer of funds. If electronic transfer of funds is selected,
please enter the required financial information to enable receipt of electronic transfer of
funds under Question 1A. If paper check is selected, please enter the required payment
address information under Question 1B.
• In completing this section, please note the following:
o The financial institution’s name must be the legal business name of that financial
institution.
o The account to which electronic transfer of funds payments is made must bear the
account holder’s name and legal business name.
o Account number should include applicable leading zeros.

23

PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
•

•

•

The third-party support entity is responsible for maintaining the accuracy of information in
this section and reporting any changes over time. Upon any change to the information in
this section, the enrollee should update the information in this form via the MTF DM. In
particular, maintaining up to date information regarding banking information, orand
arrangements between a dispensing entity and a third-party support entity managing MFP
refund payments on a dispensing entity’s behalf will beis crucial to maintaining the flow of
MFP refunds.
Under Question 1C of this section, please submit a voided check or a letter on the bank’s
letterhead for verification purposes. This helps to ensure the accuracy of account details
and prevents errors in payment processing. Only one type of documentation is needed.
When submitting the banking verification documentation, it should contain the name on the
account (account holder’s name), routing number, account number, and account type. If
submitting bank letterhead, the bank officer’s name and signature is also required. NOTE:
Supporting bank documents must be in the organization’sthird-party support entity’s legal
business name only.
Question 2 concerns tax reporting information. Nonprofit third-party support entities will
not receive an IRS Form 1099.

Section 3, Question 1. SelectWhile the MTF will keep your financial information on file, whether
you will be the recipient of MFP refund payments depends on the dispensing entity’s response in
Part I, Section 3 of this form. Accordingly, select a preference for using the MTF Payment Module.
After indicating your preference, please answer either Question 1A or Question 1B.
Field
Preference

1
2

Response Format
Drop-down menu
Drop-down Menu Options
Electronic transfer of funds (default)
Paper check

Section 3, Question 1A. If “electronic transfer of funds” was selected in response to Question 1,
please complete the table to enable electronic transfer of funds. If “paper check” was selected,
please skip to Question 1B.
ERA
Delivery
File
Transfer
Protocol
(FTP)
Address
Text

Bank
Name

Bank
Accoun
t
Holder

Bank
Account
Type

Recipient
’s Bank
Account
Number

Recipient’s Bank
Routing Number

Deleted Cells
Formatted Table
Deleted Cells
Formatted: Font: Bold, Underline

Text

TextDropdown menu

Text

Drop-down Menu Options

24

Text

Text

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together
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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
1
2

Checking
Savings

Section 3, Question 1B. If “paper check” was selected in response to Question 1, please complete
the table to enable receipt of paper checks.
Field
Payment Address
Remittance Address

Response Format
Text
Text

Section 3, Question 1C. Confirmation of Information Needed for Electronic Transfer of Funds.
To verify the banking information provided, please upload one of the following documents to your
submission: either (1) voided check for the account listed, which shows the account holder’s
name, bank account number, and routing number—ensure that the check is clearly marked as
“VOID” across the front; or, (2) letter from bank, printed on official bank letterhead, that confirms
the account holder’s name, account number, and routing number—the letter must be signed by a
representative of the bank and include their contact information for verification purposes.
[DOCUMENT UPLOAD]

Confirmation of Financial Information. To verify the banking information provided, please upload
one of the following documents to your submission: either (1) voided check for the account listed,
which shows the account holder’s name, bank account number, and routing number—ensure that
the check is clearly marked as “VOID” across the front; or, (2) letter from bank, printed on official
bank letterhead, that confirms the account holder’s name, account number, and routing number—
the letter must be signed by a representative of the bank and include their contact information for
verification purposes.
[DOCUMENT UPLOAD]

Section 3, Question 2. Please indicate whether your third-party support entity is a nonprofit
organization. A nonprofit organization is generally defined as an entity that is exempt from federal
income tax under Internal Revenue Code Section 501(c). Nonprofit third-party support entities will
not receive an IRS Form 1099.
Field
Is the third-party support entity a
nonprofit organization?

Response Format
☐ Yes
☐ No

Section 4: Third-partyParty Support Entity Contact Information
Please provide information for two points of contact within your organization. Pointsthe third-party
support entity. The designated points of contact mustin this section should be individuals who are
knowledgeable about the contents in this form and able to respond any inquiries from CMS or the
MTF if clarifications or additional information is needed. Accordingly, please ensure that the

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
designated points of contacts are familiar with the details provided on this form and can provide
timely responses.
Instructions
•
•

Both tables should be completed in their totality, with one exception regarding the number
of phone numbers.
Enter the name and title of a contact person who can answer questions about the
information submitted on this form. For each point of contact, two phone numbers are
requested, with one being required.

Instructions
•
•
•

Both tables should be completed in their totality, with one exception regarding the number
of phone numbers.
Enter the name and title of a contact person who can answer questions about the
information submitted on this form.
If a point of contact only has one phone number they can be reached at, CMS will accept
submissions with only one; if no second phone number, indicate “Not Available” using in
the relevant field.

Section 4, Question 1. Primary Point of Contact
Field
First Name

Response Format
Text

Last Name

Text

Title

Text

Email Address

Text

Phone Number (1)

Text

Phone Number (2) (optional)

Text

Section 4, Question 2. Secondary Point of Contact
Field
First Name

Response Format
Text

Last Name

Text

Title

Text

Email Address

Text

Phone Number (1)

Text

Phone Number (2) (optional)

Text

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PREDECISIONAL – DO NOT DISTRIBUTE – DO NOT CITE
Section 5. Certification of Third-Party Support Entity Submission of Sections 1 through 4.
Certification
Please finalize your submission by certifying the completeness and accuracy of the information on
the information provided.in sections 1 through 4.
Instruction for Section 5
An individual eligible to certify this submission on behalf of the third-party support entity must be
one of the following: (1) the chief executive officer (CEO) of the organization, (2) the chief financial
officer (CFO) of the organization, (3) an individual other than a CEO or CFO, who has authority
equivalent to a CEO or CFO of the organization, or (4) an individual with the directly delegated
authority to perform the certification on behalf of one of the individuals mentioned in (1) through
(3).
Certification:
I hereby certify, to the best of my knowledge, that the information being sent to CMS in this
submission is complete and accurate, and the submission was prepared in good faith and after
reasonable efforts. I reviewed the submission and made a reasonable inquiry regarding its content.
I understand the information contained in this submission is being provided to and will be relied
upon by CMS to facilitate payment of an MFP retrospective refund on MFP-eligible claims of
selected drugs from the Primary Manufacturer to the dispensing entity in accordance with section
1193(a)(3) of the Social Security Act. I also certify that I will timely notify CMS if I become aware that
any of the information submitted in this form has changed.
Yes [ ]
No [ ]
Field
Name of the Person Responsible for the Submission
Signature
Date

27

Response
Text
Text
MM/DD/YYYY

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