Information Collection

Contracted Pharmacy Services Registration and Recertifications

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3.1 Contract Pharmacy Registration.pdf Contracted Pharmacy Services Registration and Recertifications	Form
Form 3.2 Contract Pharmacy Termination.pdf Contracted Pharmacy Services Registration and Recertifications	Form
3.1 Contract Pharmacy Registration.pdf Contract Pharmacy Registration.docx.pdf	Form
3.2 Contract Pharmacy Termination.pdf Contract Pharmacy Termination.pdf	Form
Contract Pharmacy Registration Redline.pdf Contract Pharmacy Registration Redline	IC Document
Contract Pharmacy Termination Redline.pdf Contract Pharmacy Termination Redline	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	3.1				Yes	Yes	Fillable Fileable
Form	3.2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,376

Number of Respondents for Small Entity: 1,524

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	48,136	10,230	37,906
Annual IC Time Burden (Hours)	48,136	10,230	37,906
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Contract Pharmacy Registration Redline		01/08/2026
Contract Pharmacy Termination Redline		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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