Primary Manufacturer and/or Dispensing Entity to Complete Drug Price Negotiation Program Complaint and Dispute Intake Form

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

OMB:

IC ID: 274428

Documents and Forms

Document Name Document Type
Form CMS-10912 Primary Manufacturer and/or Dispensing Entity to Complete Drug Price Negotiation Program Complaint and Dispute Intake Form Form and Instruction
CMS-10912 Drug Price Negotiation Program Complaint and Dispute Intake Form 2025.03.07_MTF_ICR_Complaints&DisputesForm_clean.docx Form and Instruction
2025_03_10MTF_ICR_Complaints and Disputes Form_trackchanges.pdf Track Change - Complaints&DisputesForm IC Document