Statutory Written Counteroffer ICR Form

Drug Price Negotiation Process under Sections 11001 and 11002 of the Inflation Reduction Act (CMS-10849) - (IRA)

Documents and Forms

Document Name Document Type
Form CMS-10849 Statutory Written Counteroffer ICR Form Form and Instruction
CMS-10849 Negotiation Data Elements ICR Form and Drug Price Negoti CMS 10849 NDE Process.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Statutory Written Counteroffer ICR Form	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10849	Negotiation Data Elements ICR Form and Drug Price Negotiation Process ICR Form	CMS 10849 NDE Process.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	15	5	10
Annual IC Time Burden (Hours)	3,064	1,021	2,043
Annual IC Cost Burden (Dollars)	0	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.