CMS-10110 Bona Fide Service Fee Certification Form

Medicare Part B

Bona Fide Service Fee Certification Form

Defined under 42 CFR § 414.802 and § 414.804, CMS will require manufacturers to document and submit their assumptions quarterly for sales beginning January 1, 2026 (reflected in ASP data reported to CMS not later than April 30, 2026).

Submission Method

Manufacturers will submit their reasonable assumptions via the ASP Data Collection System. Technical assistance will also be made available. Certification forms are due by January 30, April 30, July 30, and October 30 every year along with the applicable ASP data submitted to the portal.

Section 1. Enter all drug and manufacturer information associated with the bona fide service fee

Drug Name(s):

National Drug Code(s):

Manufacturer name:

Manufacturer address:

Section 2. Recipient of BFSF information

Name and title of certifying individual:

Organization or entity name:

Organization or entity address:

Bona fide service:

Bona fide service fee amount (if the fee varies based on certain metrics, describe the conditions of the fee and how it is determined):

Section 3. Certification Statement
I certify that the fee is not passed on in whole or in part to a client or customer of an entity.	Manufacturer Signature: Fee Recipient Signature: