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Federal forms, ICRs, and supporting documents

Information Collection

Contracted Pharmacy Services Registration and Recertifications

IC 190348 under ICR 202601-0915-001 · OMB 0915-0327.

Documents and Forms
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Document Type
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Form
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Form
IC Document
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Information Collection (IC) Details

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Contracted Pharmacy Services Registration and Recertifications
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 3.1 Contract Pharmacy Registration.pdf Contract Pharmacy Registration.docx.pdf Yes Yes Fillable Fileable
Form 3.2 Contract Pharmacy Termination.pdf Contract Pharmacy Termination.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

4,376 1,524
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 48,136 0 10,230 0 0 37,906
Annual IC Time Burden (Hours) 48,136 0 10,230 0 0 37,906
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Contract Pharmacy Registration Redline Contract Pharmacy Registration Redline.pdf 01/08/2026
Contract Pharmacy Termination Redline Contract Pharmacy Termination Redline.pdf 01/08/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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