Crosswalk

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Existing Page Number: 1

Revised Page Number: 1

Existing Section: NA

Revised Section: NA

Existing Section Number: NA
Existing Data Field Text: NA

Existing Locations:

1. Introductory sentence
2. Printed Name of OPO
Representative
3. Signature of OPO Representative
4. Date Signed

Revised Section Number: NA
Revised Data Field Text: The areas that
require data input have been converted to
a .pdf fillable format.
Revised Location:
1.
2.
3.
4.

Introductory sentence
Printed Name of OPO Representative
Signature of OPO Representative
Date Signed

Description of Changes Made

Reasons for Changes Made

The CMS-576A form has been converted to a
The existing version of the CMS-576A form is not
.pdf fillable form, so that all information can be fillable. This means that the person completing the
added electronically.
form must either handwrite or type their responses
onto the form.
If responses are handwritten there is a possibility
that the handwriting may be illegible. It is time
consuming and burdensome for the provider to
attempt to properly line up the data fields in the
typewriter so as to get the information in the
correct areas

We have made these changes because it reduces
burden to the providers by being able to complete
the form quickly and easily on a computer por
tablet. The person completing the form can also
electronically sign the form. In addition, because
the form can be completed electronically, it can be
returned to CMS electronically.

Page 1 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location
Existing Page Number: 1
Section Number: NA
Section: NA

Existing Data Field Text:
“For the purpose of establishing eligibility
under titles XVIII and XIX of the Act
_________________ (insert name of facility)
hereinafter referred to as the Organ
Procurement Organization, hereby
agrees;”
Location: Introductory paragraph

Revised Section Number, Section Title,
Data Field Text & Location
Revised Page Number: 1

Revised Section Number: NA
Revised Section:

Revised Data Field Text:
“For the purpose of establishing eligibility
under titles XVIII and XIX of the Social
Security Act (“the Act”) _________________
hereinafter referred to as the Organ
Procurement Organization (OPO), hereby
agrees;”
Revised Location: Introductory
sentence.

Description of Changes Made
The introductory sentence has been changed
from:
“For the purpose of establishing
eligibility under titles XVIII and XIX of
the Act _________________ (insert name of
facility) hereinafter referred to as the
Organ Procurement Organization,
hereby agrees;” in the existing CMS
576A form
to

Reasons for Changes Made
The introductory sentence of the existing version of
the CMS-576A form refers to the Social Security Act
as “the Act.”. This is improper because this is the
first reference in this document to the Social
Security Act.
When referring to the Social Security Act the first
time in a document, one should state “Social
Security Act “ followed by the acronym “the Act.”
Therefore, we have made this change in the revised
CMS-576A form.

“For the purpose of establishing
eligibility under titles XVIII and XIX of
the Social Security Act (“the Act”)
_________________ hereinafter referred to as
the Organ Procurement Organization
(OPO), hereby agrees;” in the revised
CMS-576A form.

(Note: Revised text is highlighted in yellow).

Page 2 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Existing Page Number: 1

Revised Page Number: 1

Section: NA

Revised Section: NA

Section Number: NA

Existing Data Field Text:
“(A) To maintain compliance with the
requirements of titles XVIII and XIX of the
Act, §1138 of the Act, applicable
regulations including the conditions set
forth in Part 486, subpart G, title 42 of the
Code of Federal Regulations, those
conditions of the Organ Procurement and
Transplantation Network established
under §372 of the Public Health Service
Act that have been approved by the
Secretary, and to report promptly to the
Centers for Medicare & Medicaid Services
(CMS) any failure to do so.
Location: Paragraph A

Revised Section Number: NA
Revised Data Field Text:
“(A) To maintain compliance with the
requirements of titles XVIII and XIX of the
Act, §1138 of the Act, applicable Centers
for Medicare and Medicaid Services (CMS)
regulations, including, but not limited to
the conditions and requirements set forth
in Part 486, subpart G, title 42 of the Code
of Federal Regulations (CFR), those
conditions of the Organ Procurement and
Transplantation Network established
under §§371 and 372 of the Public Health
Service Act, and to report promptly to
CMS any failure to do so;”
Revised Location: Paragraph A

Paragraph A has been changed from:

“(A) To maintain compliance with the
requirements of titles XVIII and XIX of
the Act, §1138 of the Act, applicable
regulations including the conditions set
forth in Part 486, subpart G, title 42 of
the Code of Federal Regulations, those
conditions of the Organ Procurement
and Transplantation Network
established under §372 of the Public
Health Service Act that have been
approved by the Secretary, and to report
promptly to the Centers for Medicare &
Medicaid Services (CMS) any failure to
do so;” in the existing CMS-576A form

We have made the highlighted changes to the text of
paragraph A to make the text more accurate.

to

“(A) To maintain compliance with the
requirements of titles XVIII and XIX of
the Act, §1138 of the Act, applicable
Centers for Medicare and Medicaid
Services (CMS) regulations, including,
but not limited to the conditions and
requirements set forth in Part 486,
subpart G, title 42 of the Code of Federal
Regulations (CFR), those conditions of
the Organ procurement and
Transplantation Network established
under §§371 and 372 of the Public
Health Service Act, and to report
Page 3 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Description of Changes Made

Reasons for Changes Made

promptly to CMS any failure to do so;” in
the revised CMS-576 form

Existing Page Number: 1

Revised Page Number: 1

Section: Paragraph B

Revised Section: Paragraph B

Section Number: NA

Existing Data Field Text:
“(B) To file a cost report in accordance
with 42 CFR 413.24(f) within 5 months
after the end of each fiscal year;”

Location: Paragraph B

Revised Section Number: NA

Revised Data Field Text:
“(B) To file a cost report in accordance
with 42 CFR § 413.24(f) within 5
following the close of the period covered
by the report;”
Revised Location: Paragraph B

Note: Revised text is highlighted in yellow
Deleted text is highlighted in green

Paragraph B has been changed from:

“(B) To file a cost report in accordance
with 42 CFR 413.24(f) within 5 months
after the end of each fiscal year;” in
the existing CMS-576 A form.
to

“(B) To file a cost report in accordance
with 42 CFR § 413.24(f) within 5 months
following the close of the period
covered by the report;” in the revised
CMS-576A form,

We have changed the submission deadline from 5
months after the end of the fiscal year to 5 months
following the close of the period covered by the
report.

We made this change because not all cost reports
will be based on the fiscal year. This could occur if
an OPO is established in the middle of a fiscal year
or if the OPO does not report on a fiscal year basis,

The revised submission deadline covers both OPOs
with reporting periods based on the fiscal year and
those not based on the fiscal year.

Note: Revised text is highlighted in yellow

Page 4 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Existing Page Number: 1

Revised Page Number: 1

Existing Section: Paragraph C

Revised Section: Paragraph C

Existing Section Number: NA
Existing Data Field Text:
“(C) To permit CMS to designate an
intermediary to determine the interim
reimbursement rate payable to the
transplant hospitals for services
provided by the OPO and to make a
determination of reasonable cost based
upon the cost report filed by the OPOs;”
Existing Location: Paragraph C

Revised Section Number: NA
Revised Data Field Text:
(C) To permit CMS to designate a
contractor to determine the interim
reimbursement rate payable by the
transplant hospitals for services provided
by the Independent Organ Procurement
Organization (IOPO), and to determine
Medicare’s reasonable cost based upon
the cost report filed by the IOPOs;
Revised Location: Paragraph C

Description of Changes Made
Paragraph C has been changed from:

“(C) To permit CMS to designate an
intermediary to determine the interim
reimbursement rate payable to the
transplant hospitals for services
provided by the OPO and to make a
determination of reasonable cost based
upon the cost report filed by the OPOs;”
in the existing CMS-576A form

Reasons for Changes Made
Paragraph C of existing CMS-576A form refers to
OPOs. We have changed this to Independent Organ
Procurement Organizations (IOPOs) in the revised
CMS-576A form.
We have made these changes to the text of
paragraph C to make it accurate.

to

“(C) To permit CMS to designate a
contractor to determine the interim
reimbursement rate payable by the
transplant hospitals for services
provided by the Independent Organ
Procurement Organization (IOPO),
and to determine Medicare’s reasonable
cost based upon the cost report filed by
the IOPOs;” in the revised CMS-576A
form.

Note: Revised text is highlighted in yellow

Page 5 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Existing Page Number: 1

Revised Page Number: 1

Existing Section: Paragraph E

Revised Section: Paragraph E

Existing Section Number: NA

Revised Section Number: NA

Existing Data Field Text:
(E) To pay to CMS amounts that have been
paid by CMS to transplant hospitals and
that are determined to be in excess of the
reasonable cost of the services provided by
the OPO;

Revised Data Field Text:
(F) To pay to CMS amounts that have been
paid by CMS to transplant hospitals and
that are determined to be in excess of the
reasonable cost of the services provided
by the IOPO;

Existing Location: Paragraph E

Revised Location: Paragraph E

Existing Page Number: 1

Revised Page Number: 1

Existing Section: Attestation Statement

Revised Section: Attestation Statement

Existing Section Number: NA

Existing Data Field Text:
This agreement, upon submission by the
Organ Procurement Organization and

Revised Section Number: NA

Revised Data Field Text:
This Agreement, upon submission by the
OPO and upon acceptance for filing by CMS

Description of Changes Made
Paragraph E has been changed from:

“(E) To pay to CMS amounts that have
been paid by CMS to transplant hospitals
and that are determined to be in excess
of the reasonable cost of the services
provided by the OPO;”
in the existing CMS-576A form

Reasons for Changes Made
We have changed the reference in paragraph E to
OPO in the existing CMS-576A form to IOPO in the
revised CMS-576A form. We made this change for
accuracy.

to

“(E) To pay to CMS amounts that have
been paid by CMS to transplant hospitals
and that are determined to be in excess
of the reasonable cost of the services
provided by the IOPO;”
in the revised CMS-576 form.

Note: Revised text is highlighted in yellow

Attestation statement sentence #1 has been
changed from:
“This agreement, upon submission by the
Organ Procurement Organization and
upon acceptance for filing by the
Secretary of Health and Human
Services, shall be binding on the Organ
Procurement Organization and the

Page 6 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

upon acceptance for filing by the Secretary on behalf of the Secretary of Health and
Human Services (the Secretary), shall be
of Health and Human Services, shall be
binding on the OPO and the Secretary.
binding on the Organ Procurement
Organization and the Secretary.
Revised Location: Attestation
Statements, paragraph #1
Existing Location: Attestation
Statements, sentence #1

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Attestation Statement

Revised Section: Attestation Statements

Existing Section Number: NA

Existing Data Field Text:
The agreement may be terminated by
either party in accordance with regulatory
requirements. In the event of decertification, costs for the procurement of
organs will not be available to the Organ
Procurement Organization furnished on or
after the effective date of the decertification.

Revised Section Number: NA

Revised Data Field Text:
This Agreement may be terminated by
either party in accordance with regulatory
requirements. In the event of decertification, costs for the procurement of
organs will not be available to the OPO
furnished on or after the effective date of
the de-certification.

Description of Changes Made

Reasons for Changes Made

Secretary” in the existing CMS-576A
form
to

“This Agreement, upon submission by
the OPO and upon acceptance for filing by
CMS on behalf of the Secretary of Health
and Human Services (the Secretary), shall
be binding on the OPO and the Secretary”
in the revised CMS-576A form.

Note: Revised text is highlighted in
yellow).

Attestation statement sentences #2 & #3 have
been changed from:
“The agreement may be terminated by
either party in accordance with
regulatory requirements. In the event of
de-certification, costs for the
procurement of organs will not be
available to the Organ Procurement
Organization furnished on or after the
effective date of the de-certification” in
the existing CMS-576A form
to

Page 7 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location
Existing Location: Attestation
Statements, sentences #2 & #3

Revised Section Number, Section Title,
Data Field Text & Location
Revised Location: Attestation
Statements, paragraph #2

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Attestation Statement

Revised Section: Attestation Statements

Existing Section Number: NA

Existing Data Field Text:
This agreement shall become effective on
the date specified below by the Secretary
or his Delegate, and shall remain in effect
as specified by 42 CFR 486.309 unless the
OPO is de-certified.

Revised Section Number: NA

Revised Data Field Text:
This Agreement shall become effective on
the date specified below by the Secretary
or its’ Delegate, and shall remain in effect
as specified by 42 CFR §486.309 unless
the OPO is de-certified.

Existing Location: Attestation Statement, Revised Location: Attestation Statement,
4th sentence
paragraph #3.

Description of Changes Made

Reasons for Changes Made

“This Agreement may be terminated by
either party in accordance with
regulatory requirements. In the event of
de-certification, costs for the
procurement of organs will not be
available to the OPO furnished on or
after the effective date of the decertification” in the revised CMS-576A
form.

Note: Revised text is highlighted in yellow.

The 4th sentence of the attestation statement
has been changed from:
“This agreement shall become effective
on the date specified below by the
Secretary or his Delegate, and shall
remain in effect as specified by 42 CFR
486.309 unless the OPO is de-certified” in
the existing CMS-576A form
to

“This Agreement shall become effective
on the date specified below by the
Secretary or its’ Delegate, and shall
remain in effect as specified by 42 CFR
§486.309 unless the OPO is de-certified’
in the revised CMS=576A form.

1. We have changed the pronoun used to refer to
the Secretary from “his” to “its’”. We made this
change because this is the modern term used.
2. We have changed the format of the attestation
statement from a paragraph containing 5
sentences to 3 separate paragraphs.

We made this change because the person
signing the form should thoroughly read and
understand the attestation statement text before
signing the CMS-576A form. We believe that the
person completing the CMS-576A form would be
less likely to do so when this important text,
containing 5 separate pieces of information is
buried into a paragraph that is presented in very
small text as opposed to being presented in
larger text in 3 separate paragraphs, with the
Page 8 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Signature section

Revised Section: Signature section

Existing Section Number: NA

Existing Data Field Text:
“FOR THE ORGAN PROCUREMENT
ORGANIZATION”

Existing Location: Signature section title
row

Revised Section Number: NA

Revised Data Field Text:
“Agreement Entered Into On Behalf of the
OPO By:”
Revised Location: Signature section title
row

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Signature section

Revised Section: Signature section

Existing Section Number: NA
Existing Data Field Text:
“Name”

Existing Location: Signature section,
Name field

Revised Section Number: NA
Revised Data Field Text:
“Printed Name”

Revised Location: Signature section,
Printed Name field

Description of Changes Made
Note: Revised text is highlighted in yellow.
The text of the title row for the signature
section of the CMS-576A form has been
changed from:
“FOR THE ORGAN PROCUREMENT
ORGANIZATION” in the existing CMS576A form

Reasons for Changes Made
words “This Agreement” in larger bold ed
text at the beginning of each paragraph.

We have changed the text of the title row to the
signature section in the revised CMS-576A form
because we believe that the revised text is more
accurate,

to

“Agreement Entered Into On Behalf of
the OPO By:” in the revised CMS-576A
form.

1. The Name field in the signature section of
the CMS-576A form has been changed
from:
“Name” in the existing CMS-576A form
to

“Printed Name” in the revised CMS576A form

In the existing CMS-576A form, the first line in the
1st column of signature section is for “Name” of the
person from the OPO that is signing the form.
However, it is not indicated whether the person is
to write their printed name or sign the form in this
space.

Also, such a form should require a signature from a
designated representative from the OPO who has
the authority to bind the OPO to such an agreement.
However, the signature of many persons is illegible.
Page 9 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Description of Changes Made

Reasons for Changes Made
Therefore, it is wise to also have a place for the
person signing the form to add their printed name.
The existing CMS-576A form has only a Name, Title
and Date spaces.
To correct these issues we have done the following:
1. Changed the text in the “Name” data field to
“Printed Name”; and
2. Added a new data field in the signature
section as row 3 for “Signature of OPO
Representative.”

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Signature section

Revised Section: Signature section

Existing Section Number: NA
Existing Data Field Text:
NA
Existing Location: None

Revised Section Number: NA

Revised Data Field Text:
“Signature of OPO Representative”

Revised Location: Signature section,
column 1, row 3

3. Converted all data fields in the signature
section to a .pdf fillable format.

We have added a new data field for “Signature In the existing CMS-576A form, the first line in the
of OPO Representative” at column 1, row 3 of 1st column of signature section is for “Name” of the
the revised CMS-576A form.
person from the OPO that is signing the form.
However, it is not indicated whether the person is
to write their printed name or sign the form in this
space.

Also, such a form should require a signature from a
designated representative from the OPO who has
the authority to bind the OPO to such an agreement.
However, the signature of many persons is illegible.
Therefore, it is wise to also have a place for the
person signing the form to add their printed name.
Page 10 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Description of Changes Made

Reasons for Changes Made
The existing CMS-576A form has only a Name, Title
and Date spaces.

To correct these issues we have done the following:
1. Changed the text in the “Name” data field to
“Printed Name”; and
2. Added a new data field in the signature
section as row 3 for “Signature of OPO
Representative.”

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Signature section

Revised Section: Signature section

Existing Section Number: NA
Existing Data Field Text:
“Date”

Existing Location: Signature section,
column 1, row 3

Revised Section Number: NA
Revised Data Field Text:
Date Signed”

Revised Location: Signature section,
column 1, row 4

1. The text in column 1, row 3 of the
signature section of the CMS-576A form
has been changed from:
“Date” in the existing CMS-576A form
to

“Date Signed” in the revised CMS-576A
form.

2. Due to the addition of the signature
data field as column 1, Row 3 in the
signature section of the revised CMS-

3. Converted all data fields in the signature
section to a .pdf fillable format.

We believe that the word “Date” by itself could be
confusing to the person completing the CMS-576A
form. For example. the form could be completed on
one date but signed at a later date. The person
completing the CMS-576A form may not know
whether to use the date the form was completed or
the date the form was signed in this “Date” field,
We have changed the text of the date field from
“Date” to “Date Signed” to provide more specificity.

Page 11 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Description of Changes Made

Reasons for Changes Made

576A form, the “Date Signed” data field
has been moved from
Column 1, row 3 in the existing CMS576A form
to

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Signature section

Revised Section: Signature section

Existing Section Number: NA
Existing Data Field Text:
“Name”

Existing Location: Signature section,
column 2, row 1

Revised Section Number: NA

Revised Data Field Text:
“Printed Name of CMS Representative”
Revised Location: Signature section,
column 2, row 1

Column 1, row 4 in the revised CMS576A form.

The Name field in column 2, row 1 of the
signature section of the CMS-576A form has
been changed from:
“Name” in the existing CMS-576A form
to

“Printed Name CMS Representative” in
the revised CMS-576A form

In the existing CMS-576A form, the first line in the
2nd column of signature section is for “Name” of the
person from CMS that is signing the form. However,
it is not indicated whether the person is to write
their printed name or place their signature in this
space.
Also, such a form should require a signature from a
designated representative from CMS who has the
authority to make this agreement with the OPO
binding. However, the signature of many persons is
illegible. Therefore, it is wise to also have a place
for the person signing the form to add their printed
name. The existing CMS-576A form has only a
Name, Title and Date spaces.
To correct this issue we have done the following:

Page 12 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Description of Changes Made

Reasons for Changes Made
1. Changed the text in the “Name” data field to
“Printed Name of CMS Representative”; and

2. Added a new data field in the signature section
at column 2, row 3 for “Signature of CMS
Representative.”

Existing Page Number: 1

Revised Page Number: 2

Existing Section: Signature section

Revised Section: Signature section

Existing Section Number: NA
Existing Data Field Text:
NA
Existing Location: NA

Revised Section Number: NA

Revised Data Field Text:
“Signature of CMS Representative”

Revised Location: Signature section,
column 2, row 3

3. Converted all data fields in the signature section
to a .pdf fillable format.

We have added a new data field for “Signature In the existing CMS-576A form, the first line in the
of CMS Representative” at column 2 row 3 of
2nd column of signature section is for “Name” of the
the revised CMS-576A form.
person from CMS that is signing the form. However,
it is not indicated whether the person is to write
their printed name or place their signature in this
space.
Also, such a form should require a signature from a
designated representative from CMS who has the
authority to make this agreement with the OPO
binding. However, the signature of many persons is
illegible. Therefore, it is wise to also have a place
for the person signing the form to add their printed
name. The existing CMS-576A form has only a
Name, Title and Date spaces.
To correct this issue we have done the following:

Page 13 of 14

Revisions to Form CMS-576A
HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
Current Section Number, Section Title,
Data Field Text and Location

Revised Section Number, Section Title,
Data Field Text & Location

Description of Changes Made

Reasons for Changes Made
1. Changed the text in the “Name” data field to
“Printed Name of CMS Representative”; and

2. Added a new data field in the signature section
at column 2, row 3 for “Signature of CMS
Representative.”

3. Converted all data fields in the signature section
to a .pdf fillable format.

Page 14 of 14