Information Collection

Primary Manufacturer and/or Dispensing Entity to Complete Drug Price Negotiation Program Complaint and Dispute Intake Form

IC 274428 under ICR 202503-0938-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10912 Primary Manufacturer and/or Dispensing Entity to Complete Drug Price Negotiation Program Complaint and Dispute Intake Form	Form and Instruction
Form CMS-10912 CMS-10912. 2025.05.08_MTF_ICR_Complaints&DisputesForm_clean Primary Manufacturer and/or Dispensing Entity to Complete Drug Price Negotiation Program Complaint and Dispute Intake Form	Form and Instruction
CMS-10912 Drug Price Negotiation Program Complaint and Dispute Int 2025.03.07_MTF_ICR_Complaints&DisputesForm_clean.docx	Form and Instruction
CMS-10912 CMS-10912. 2025.05.08_MTF_ICR_Complaints&DisputesForm_cl CMS-10912. 2025.05.08_MTF_ICR_Complaints&DisputesForm_clean.docx	Form and Instruction
2025_03_10MTF_ICR_Complaints and Disputes Form_trackchanges.pdf Track Change - Complaints&DisputesForm	IC Document
2025_03_10MTF_ICR_Complaints and Disputes Form_trackchanges.pdf Track Change - Complaints&DisputesForm	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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: 11,425

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,425	11,425
Annual IC Time Burden (Hours)	293,100	293,100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - Complaints&DisputesForm		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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