Non-MTF User to Complete Drug Price Negotiation Program MTF DM Complaint Intake 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-10912 Non-MTF User to Complete Drug Price Negotiation Program MTF DM Complaint Intake Form Form and Instruction
CMS-10912 Drug Price Negotiation Program Complaint Information Col non MTF User Form Complaints_v2.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

Information Collection (IC) Details

IC Title:	Non-MTF User to Complete Drug Price Negotiation Program MTF DM Complaint Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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. 2025.05.08_MTF_ICR_Complaints&DisputesForm_clean	CMS-10912. 2025.05.08_MTF_ICR_Complaints&DisputesForm_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: 25,050	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,050	25,050
Annual IC Time Burden (Hours)	50,100	50,100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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