CMS-10520 Vendor Appeal Form

OMB No. 0938-1249: Approval Expires XX/XX/XXXX

Qualified Health Plan Enrollee Experience Survey

2020 Request for Appeal Form

Organization Name:				Date Submitted:
Address:
Primary Contact:				Title:
Telephone:		Email:

Please provide new or additional information in the response section(s) below for each Criterion Not Met that is being appealed and a justification for the initial exclusion of this information from your organization’s 2020 QHP Enrollee Survey Vendor Participation Form.

Criterion Not Met:

New or Additional Information:

Justification for Exclusion from Vendor Participation Form:

Criterion Not Met:

New or Additional Information:

Justification for Exclusion from Participation Form:

Submit the appeal form to the Project Team via email at the following address: [email protected]. Please include the following in the subject line: “[Vendor Name] 2020 Vendor Appeal Form”.

According to the Paperwork Reduction Act of 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 0938-1249. The time required to complete this information collection is estimated to average 2 hours per response. 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.