Form CMS-10515 Enrollment and Payment Data Template Submission Accuracy

[to be printed on Issuer letterhead]

Enrollment and Payment Data Template

Submission Certification Form

I certify in my capacity as a financial authority contact (i.e., CEO or CFO or authorized delegate) of [Organization Name (Issuer or SBM)] that I have reviewed the information on the Enrollment and Payment Data Template(s) submitted to the Centers for Medicare & Medicaid Services (CMS). I further certify that to the best of my knowledge, information and belief, the information is accurate, the information provided as of this submission date is a good faith estimate. I understand the information included in this submission will be the basis for the calculation of the amount to be paid to, or collected from, [Organization Name], if any, in the month of [Month] on an interim basis. This amount will be reconciled by the Federal government once the regular payment process is fully implemented. This certification applies to the submission dated [xx/xx/2013] for the following HIOS Issuer IDs:

[List HIOS IDs here]

This certification includes non-submission of Enrollment and Payment Data Template(s) for the HIOS Issuer IDs listed below because these issuers had zero effectuated enrollments as of December 15^th, 2013. I and [Issuer Name] understand that these IDs will be excluded from any payment calculation in the month of [Month]. `

[List HIOS IDs here]

Name of the Person Completing this form (Print or Type):

_________________________________________

Title: _____________________________________

Organization: ______________________________

Telephone: ________________________________

Fax Number: _______________________________

Email Address: ______________________________

Signature: _________________________________ Date: ___________________