Form CMS-10198 DIsclosure to CMS Web Page

Disclosure to CMS Web Page 6

These screen shots from the Disclosure to CMS Form include references from the Disclosure to CMS guidance. The Disclosure to CMS form must be completed on-line at https://www.cms.hhs.gov/apps/ccdisclosure/ .

The disclosure to CMS web form below is not valid for submission to CMS.

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SAMPLE DISCLOSURE FORM – NOT FOR SUBMISSION TO CMS

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BOX B

SAMPLE DISCLOSURE FORM – NOT FOR SUBMISSION TO CMS

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Box C - All Options Offered Are Creditable

SAMPLE DISCLOSURE FORM – NOT FOR SUBMISSION TO CMS

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Box D - All Options Offered Are Non-Creditable

SAMPLE DISCLOSURE FORM – NOT FOR SUBMISSION TO CMS

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Box E-There are some Creditable or Non-Creditable Options Offered

SAMPLE DISCLOSURE FORM – NOT FOR SUBMISSION TO CMS

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BOX E

SAMPLE DISCLOSURE FORM – NOT FOR SUBMISSION TO CMS

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BOX F

SAMPLE DISCLOSURE FORM – NOT FOR SUBMISSION TO CMS

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-NEW. The time required to complete this information collection is estimated to average 5 minutes 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.