Information Collection

DDR Product Data (CMS-367c)

IC 222506 under ICR 202606-0938-019 · OMB 0938-0578.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-367c MDP Product Data DDR Product Data (CMS-367c)	Form and Instruction
CMS-367c MDP Product Data CMS-367c_Clean_508.pdf	Form and Instruction
CMS-367c_REDLINE.pdf Redline: CMS-367c (MDP Product Data)	IC Document
CMS-367c Crosswalk_508.pdf Crosswalk: CMS-367c (MDP Product Data)	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 and Instruction	CMS-367c				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 840

Number of Respondents for Small Entity: 0

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	840	22	818
Annual IC Time Burden (Hours)	36,540	957	35,583
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Redline: CMS-367c (MDP Product Data)		06/26/2026
Crosswalk: CMS-367c (MDP Product Data)		06/26/2026

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

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