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

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