Form CMS-10495 Attestation

OMB Control No: 0938-1237
Expiration Date: XX/2022

Screen Shots Submission Flow
The screen shots below illustrate the workflow (submission + Attestation) of a user uploading a file
containing general payments records.
File Upload-General Payments

[Type here]
Select criteria for file upload

Successful File Upload

2

[Type here]
Payments passed file level validation check and ready for FINAL Submission

Final Submission Button Enabled for final Submission

3

[Type here]

Final Submission Confirmation

Post Final Submission Confirmation

4

[Type here]
Begin Attestation

Attestation-Confirm Payments

5

[Type here]
Add Assumptions Yes/No?

Add Assumptions- Yes workflow

6

[Type here]
Assumptions Added

Agree To Attestation

7

[Type here]
Agree to Attestation_Cont

Agree to Attestation_Cont

8

[Type here]
Review and Attest

Review and Attest

9

[Type here]
Records shown as attested

10