Dispensing Entity to Complete Drug Price Negotiation Program MTF DM Dispensing Entity and Third-Party Support Entity Enrollment Form

Medicare Transaction Facilitator for 2026 and 2027 under Sections 11001 and 11002 of the Inflation Reduction Act (IRA) (CMS-10912)

OMB:

IC ID: 274425

Documents and Forms

Document Name Document Type
Form CMS-10919 Dispensing Entity to Complete Drug Price Negotiation Program MTF DM Dispensing Entity and Third-Party Support Entity Enrollment Form Form and Instruction
CMS-10919 MTF DM Dispensing Entity and Third-Party Support Entity Enrollment Form 2025.03.07_MTF_ICR_DispensingEntityEnrollmentForm_clean.docx Form and Instruction
2025_03_10MTF_ICR_Dispensing Entity Enrollment Form_track changes.pdf Track Change - Dispensing Entity Enrollment Form IC Document