CMS-10636 Provider HSD Table

*SSA
State/County
Code

*Name of
Physician or
Mid-Level
Practitioner

*National
Provider
Identifier (NPI)
Number

Specialty

*Specialty
Code

Contract Type

*Street
Address

*City

*State

*ZIP Code

RPPO-Specific
Name of
Uses CMS MA
Letter of
If PCP, Accepts
Exception to
Medical Group
Contract
Intent Signed
New Patients?
Written
Affiliation or Amendment?
by Both
(Y/N)
Agreements?
(Y/N)
"DC"
Parties? (Y)
(Y/N)

PRA Disclosure Statement This form is required by CMS to determine MAO compliance with network
adequacy criteria under §422.116 and requirements under §§417.414, 417.416, 422.112(a)(1)(i), and
422.114(a)(3)(ii). The form is required when CMS performs a contract-level network review. Use of this form is
considered mandatory under the authority of Section 1852(d)(1) of the Social Security Act which permits an
MAO to select the providers from which an enrollee may receive covered benefits. Under the Privacy Act of
1974 any personally identifying information obtained will be kept private to the extent of the law.
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 0938-1346 (Expires: XX/XX/20XX). The time required to complete this information collection is
estimated to average 16 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.