ASETT_Assessment_Follow_Up_Request_For_Information_Letter_v_1.1_Final_508

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-17
Baltimore, Maryland 21244-185
Follow-up Request Letter
Date of Notice: FULL DATE
CONTACTNAME
JOBTITLE
CENAME
ADDRESS1
ADDRESS2
CITY, ST ZIP
Re: Assessment Number XXXXX
Dear TITLE LASTNAME:
In a letter dated (month, day, year), we informed you that was
randomly selected for an assessment of the HIPAA mandated transactions, unique identifiers,
code sets and operating rules. In that letter, we requested specific data and information be
provided within 10 business days in order for DNS to conduct the assessment. To date, this
requested information has not been received by our office. It is the covered entity’s responsibility
to provide requested information, as well as cooperate with compliance assessment reviews, as
per 45 CFR Part 160.310.
Using the previously provided login information, please upload all requested artifacts in this
letter to your secure portal site by (month, day, year) so that the assessment can be conducted.
Failure to provide this information as requested may warrant further action, as described in 45
CFR 160.314, by DNS.
If you have questions regarding your assessment, please send an email to:
[email protected].
Sincerely,
Madhu Annadata, Director
Division of National Standards
Office of Information Technology
In accordance with the Paperwork Reduction Act (1995), no persons are required to respond to a collection of information, unless it
displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information
collection is 0938-XXXX (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average
[10 hours] per response (4 forms x 60 minutes/form), 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:
Centers for Medicare & Medicaid Services
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Any correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact: Cecily Austin at [email protected] or Kevin Stewart at
[email protected] .