CMS-10141 Compensation Certification

Attachment 1a - To be completed by all Organizations

2019 Compensation Certification
Organization Name:________________________________________
Certification Date:_______________________________________
CMS Contract Number(s):___________________________________
I have examined the compensation structure(s) described
herein and attest that this accurately and completely
represents the compensation structure(s) as of the
certification date indicated on this document. The
structure(s) herein meet the requirements set in CMS 4182F.
__________________________________
CEO (or other authorized official)

___________
Date

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 (Expires: 10/18). 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.

Attachment 1b – To be completed by Organizations using
Option One to determine 2019 renewal commissions

2019 Compensation Certification
Organization Name:________________________________________
Certification Date:_______________________________________
CMS Contract Number(s):___________________________________
I have examined the compensation structure(s) for 2016
described herein and attest that this accurately and
completely represents the initial compensation structure(s)
in place at that time, and that the renewal compensation
rate submitted for 2019 is 50% of the 2016 initial rate
adjusted for inflation factors provided in CMS guidance on
2019 compensation structures. The structure(s) herein meet
the requirements set in CMS 4182-F.
__________________________________
CEO (or other authorized official)

___________
Date

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 (Expires: 10/18). 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.