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 0938-0578. The time required to complete this information collection is estimated to average 39.8 hours per response, including the time to review instructions, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
| File Type | application/msword |
| File Title | Disclosure Statement |
| Author | HCFA Software Control |
| File Modified | 2012-07-27 |
| File Created | 2012-07-27 |