CMS-10476 MLR Data Form

MLR Data Form for Contract Year 2018
General Information
Contract Year
Organization Name
Contract Number
Adjusted MLR
Remittance Amount
Date MLR Data Form Finalized
Contacts for any questions from CMS regarding
the above information:
Contact #1
Name, Position
Phone Number
E-mail Address
Contact #2
Name, Position
Phone Number
E-mail Address

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 0938-1232. The time required to complete this
information collection is estimated to average 36 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.

2018