Form CMS-10110 Addendum B

Addendum B
The Centers for Medicare & Medicaid Services
Average Sales Price Data
Name of Drug or Biological Manufacturer (as “manufacturer” is defined in section
1927(k)(5) of the Social Security Act):

Legal Address:

Manufacturer Contact(s):
Name:

Email:

Title:

Fax:

Address:

Telephone No.:

Name:

Email:

Title:

Fax:

Address:

Telephone No.:

I certify that the reported Average Sales Prices were calculated accurately and that all
information and statements made in this submission are true, complete, and current to
the best of my knowledge and belief and are made in good faith. I understand that
information contained in this submission may be used for Medicare reimbursement
purposes.
Name of CEO, CFO or Authorizing Official:
Title:

Signature

Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-0921.
The time required to complete this information collection is estimated to average (13
hours) per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. CMS
10110 approval XX/XX/XXXX