Form CMS-10141 Compensation Certification to be Completed by All Organi

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
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