Information Collection

Dispensing Entity to Complete Drug Price Negotiation Program MTF DM Dispensing Entity and Third-Party Support Entity Enrollment Form

IC 274425 under ICR 202503-0938-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10919 Dispensing Entity to Complete Drug Price Negotiation Program MTF DM Dispensing Entity and Third-Party Support Entity Enrollment Form	Form and Instruction
Form CMS-10912 CMS-10912.MTF_ICR_DispensingEntityEnrollmentForm_clean Dispensing Entity to Complete Drug Price Negotiation Program MTF DM Dispensing Entity and Third-Party Support Entity Enrollment Form	Form and Instruction
CMS-10919 MTF DM Dispensing Entity and Third-Party Support Entity 2025.03.07_MTF_ICR_DispensingEntityEnrollmentForm_clean.docx	Form and Instruction
CMS-10912 CMS-10912.MTF_ICR_DispensingEntityEnrollmentForm_clean CMS-10912.MTF_ICR_DispensingEntityEnrollmentForm_clean.docx	Form and Instruction
2025_03_10MTF_ICR_Dispensing Entity Enrollment Form_track changes.pdf Track Change - Dispensing Entity Enrollment Form	IC Document
2025_03_10MTF_ICR_Dispensing Entity Enrollment Form_track changes.pdf Track Change - Dispensing Entity Enrollment Form	IC Document

IC Title:

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-10912				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56,860

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56,860	56,860
Annual IC Time Burden (Hours)	460,560	460,560
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - Dispensing Entity Enrollment Form		03/19/2025

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

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