CMS-10141 Writing Agents Information Sheet

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Overview

Contracting Org Info Sheet
Writing Agents (Plan Paid)
PRA Disclosure Statement

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Sheet 1: Contracting Org Info Sheet

Plan Contracted Marketing Organization Information Sheet
Compensation Structure: Unique Identifying number	Number of agents covered by compensation structure	Marketing Organization Name
		Full Name	Street Address	City	State	ZIP Code	Contact Name	Contact Phone # (include area code)	Contact Email

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Sheet 2: Writing Agents (Plan Paid)

Writing Agents Information Sheet
Compensation Structure: Unique Identifying number	Number of agents covered by compensation structure
Not Applicable

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Sheet 3: PRA Disclosure Statement

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 0938-0964. The time required to complete this information collection is estimated to average 49 hours 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.