CMS-10433 Service Area Template

OMB control number: 0938-1187
Expiration Date: XX/XX/20XX

2022 Service Area v11.0 [assAll fields with an asterisk ( * ) are required
through the document. If macros are

To validate, press the Validate button or Ctrl + Shift + I. To finalize, press the Finalize button or Ctrl + Shift + F
Click Create Service Area IDs button (or Ctrl + Shift + R) to Create Service Area IDs based on your state
Service Area IDs will populate in the drop-down box in Service Area ID column
For each row, enter one County for that Service Area ID (unless the Service Area covers entire state)

HIOS Issuer ID:*
Issuer State:*

Service Area ID*
Required:
Enter the Service Area ID

Service Area Name*
Required:
Enter the Service Area Name

State*

County Name

Partial County

Required:
Required if State is "No":
Required if State is "No":
Does this Service Area cover Select the County - FIPS this Service Area Does this Service Area include a
the entire state?
covers
partial county?

PRA DISCLOSURE:
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 for this
information collection is 0938-1187, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 24.50 hours issuer per year, including the time to
review instructions, gather the information 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 document 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 Nicole Levesque at [email protected].