CMS-1561A (Tracked version)

Department of Health & Human Service Form Approved

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

HEALTH INSURANCE BENEFITS AGREEMENT

(Agreement with Rural Health Clinic Pursuant to Section 1861(aa)(2)(K)(ii) of the Social Security Act) (CMS-1561A)

For the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act,

hereafter referred to as the Rural Health Clinic, hereby agrees:

1. To maintain compliance with the conditions for certification set forth in part 491 of chapter IV, title 42 of the Code of Federal Regulations, and to report promptly to the Centers for Medicare & Medicaid Services any failure to do so;

2. Not to charge the beneficiary or any other person for items and services for which the beneficiary is entitled to have payment made under the provisions of part 405 of chapter IV, title 42 of the Code of Federal Regulations (or for which the beneficiary would have been entitled if the Rural Health Clinic had filed a request for payment in accordance with §410.165 of chapter IV), except for any deductible or coinsurance amounts for which the beneficiary is liable under §405.2410;

3. To refund as promptly as possible any money incorrectly collected from a beneficiary or from someone on his or her behalf;

4. To accept beneficiaries for care and treatment without limitations, except as it may impose on all other persons;

5. To accept any additional provisions that the Secretary finds necessary or desirable for the efficient and effective administration of the Medicare program.

This agreement, upon submission by the Rural Health Clinic and upon acceptance for filing by the Secretary of Health and Human Services, shall be binding on the Rural Health Clinic and the Secretary. The agreement may be terminated by either party in accordance with regulations. In the event of termination, payment will not be available for Rural Health Clinic services furnished on or after the effective date of termination.

This agreement shall become effective on the date specified below by the Secretary or the Secretary’s delegate, and shall remain in effect unless terminated.

In the event of a transfer of ownership, the 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).

Department of Health & Human Service Form Approved

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

Accepted for Rural Health Clinic By:

Signature	Title
Printed Name	Date

Accepted for Secretary of Health & Human 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 CMS Survey Operations Group Location.

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