CMS-10237 Medicare Advantage Provider HSD Table

Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application Regulations under 42 CFR 422 (Subpart K) & 417.400 (CMS-10237)

CY2017 CMS MA Provider HSD Table 30 Day

Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application

OMB: 0938-0935

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0935 can be found here:

2022-10-13 - Revision of a currently approved collection
2020-01-07 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

2017 CMS MA Provider HSD Table

SSA State/County
Code

Name of Physician or
Mid-Level Practitioner

National Provider
Identifier (NPI)
Number

Specialty

Specialty Code

Contract Type

Provider Street
Address

Provider City

Provider State

Provider Zip Code

If PCP, Accepts New
Patients? (Y or N)

Name of Medical
Group Affiliation or
"DC"

Uses CMS MA
Contract Amendment
(Y or N)

File Type	application/pdf
File Title	HSD Table Templates
Author	CGI Federal
File Modified	2015-09-18
File Created	2015-09-18