CMS-10725 QHP Issuer Transparency Attestation

OMB Control Number: 0938-NEW
Expiration Date: XX/XX/2023

Qualified Health Plan Issuer Transparency for Qualified Health Plans Attestation
Appendix E – Attestation
Section 1150A of the Social Security Act requires an issuer of Qualified Health Plans (QHP)
offered through an Exchange to report the certain prescription drug and pharmacy benefit
management financial data to the Centers for Medicare and Medicaid Services (CMS). The
official listed below, signing on behalf of
(“the QHP
issuer”), makes the following attestation concerning the accompanying data reporting:
I attest that I am aware of what is included in the QHP issuer’s data reporting. I attest on behalf
of the QHP issuer (based on best knowledge, information, and belief), that the data submitted to
CMS are accurate, complete, and truthful.

Name of QHP Issuer

Printed Name of QHP Issuer Official Authorized
to Sign

Date

Signature of QHP Issuer Official Authorized to
Sign

Title/Position

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-NEW
(Expires XX/XX/2023). The time required to complete this information collection is estimated to average 193 hours per
response, including the time to review instructions, search existing data resources, and gather the data needed, and
complete the template 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 Ken Buerger
at
[email protected], or LeAnn Brodhead at [email protected].