CMS-1561 (tracked version)

Department of Health & Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0832

HEALTH INSURANCE BENEFIT AGREEMENT

(Agreement with Provider Pursuant to Section 1866 of the Social Security Act (as amended) and Title 42 Code of Federal Regulations (CFR) Title IV, Part 489)

AGREEMENT

Between

THE SECRETARY OF HEALTH AND HUMAN SERVICES

and

(Insert name of provider)

doing business as (D/B/A)

In order to receive payment under title XVIII of the Social Security Act,

D/B/A

(Insert business name of

provider, if applicable)

(Insert name of provider)

(Insert business name of

provider, if applicable)

as the provider of services, agrees to conform to the provisions of section of 1866 of the Social Security Act and applicable provisions in 42 CFR.

This agreement, upon submission by the provider of services of acceptable assurance of compliance with title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973 as amended, and upon acceptance by the Secretary of Health and Human Services, shall be binding on the provider of services and the Secretary.

In the event of a transfer of ownership, this agreement is automatically assigned to the new owner subject to the conditions specified in this agreement and 42 CFR 489, to include existing plans of correction and the duration of this agreement, if the agreement is time limited.

ATTENTION: Read the following provision of Federal law carefully before signing.

Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or make any false, fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both (18 U.S.C. section 1001).

ACCEPTED FOR PROVIDER OF SERVICES BY:

Signature	Title
Printed Name	Date

Department of Health & Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0832

Title

Signature

ACCEPTED BY THE SECRETARY OF HEALTH AND HUMAN SERVICES BY:

Signature	Title
Printed Name	Date

Title

Signature

ACCEPTED FOR THE SUCCESSOR PROVIDER OF SERVICES BY:

Signature	Title
Printed Name	Date

PRA Disclosure Statement

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 0938-0832 (Expires 01/31/2027). This is a mandatory information collection. The time required to complete this information collection is estimated to average 1 hour 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 Disclosure****

Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact your respective Medicare Administrative Contractor (MAC) or State Survey Agency.

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Form CMS-1561 / OMB Approval Expires 01/31/2027