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

Medicare Transaction Facilitator for 2026 and 2027 under Sections 11001 and 11002 of the Inflation Reduction Act (IRA) (CMS-10912)

Documents and Forms

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
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

Information Collection (IC) Details

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

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10912	CMS-10912.MTF_ICR_DispensingEntityEnrollmentForm_clean	CMS-10912.MTF_ICR_DispensingEntityEnrollmentForm_clean.docx		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 %

	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

Title	Document	Date Uploaded
Track Change - Dispensing Entity Enrollment Form	2025_03_10MTF_ICR_Dispensing Entity Enrollment Form_track changes.pdf	03/19/2025

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