Form CMS-10652 Virtual Group Agreement Template

Appendix A
Virtual Group Agreement Template
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 0938-1343 (Expiration date: XX/XX/XXXX). The time
required to complete this information collection is estimated to average 10 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. ****CMS Disclosure**** Please do not send applications,
claims, payments, medical records or any documents containing sensitive information to the
PRA Reports Clearance Office. Please note that 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 [email protected].

Sample Introductory Paragraph:
This Virtual Group Agreement (“Agreement”) is by and between Virtual Group Identifier
provided by the Centers for Medicare & Medicaid Services, and XYZ Group Practice P.C.
(“virtual group member”) and is effective [Month, Day, Year] (“Effective Date”).

Sample Signature Page:
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by the duly
authorized representatives as of the dates below.
Virtual Group Member/National Provider Identifier
_________________________________________
Signature

Virtual Group Member/National Provider Identifier
_________________________________________
Signature

Virtual Group Member/National Provider Identifier
_________________________________________
Signature

Virtual Group Member/National Provider Identifier
_________________________________________
Signature