Form CMS-1561 Health Insurance Benefits Agreement

Department of Health & Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0832
__________________________________________________________________________________________________

HEALTH INSURANCE BENEFIT AGREEMENT

(Agreement with Provider Pursuant to Section 1866 of the Social Security Act (as amended)
and Title 42 Code of Federal Regulations (CFR) Title IV, Part 489)

______________________________________________________________________________
AGREEMENT

Between
THE SECRETARY OF HEALTH AND HUMAN SERVICES
and
doing business as (D/B/A)
In order to receive payment under title XVIII of the Social Security Act,

D/B/A
as the provider of services, agrees to conform to the provisions of section of 1866 of the Social Security Act
and applicable provisions in 42 CFR.
This agreement, upon submission by the provider of services of acceptable assurance of compliance with title
VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973 as amended, and upon
acceptance by the Secretary of Health and Human Services, shall be binding on the provider of services and the
Secretary.
In the event of a transfer of ownership, this agreement is automatically assigned to the new owner subject to the
conditions specified in this agreement and 42 CFR 489, to include existing plans of correction and the duration
of this agreement, if the agreement is time limited.
ATTENTION: Read the following provision of Federal law carefully before signing.
Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and
willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or make any false,
fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing the
same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or
imprisoned not more than 5 years or both (18 U.S.C. section 1001).
ACCEPTED BY PROVIDER OF SERVICES:
Signature

Title

Printed Name

Date

Form CMS-1561 / OMB Approval Expires XX/XX/20XX

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Department of Health & Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0832
__________________________________________________________________________________________________

HEALTH INSURANCE BENEFIT AGREEMENT
CMS-1561 (continued)

ACCEPTED BY THE SECRETARY OF HEALTH AND HUMAN SERVICES BY:

Signature

Title

Printed Name

Date

ACCEPTED FOR THE SUCCESSOR PROVIDER OF SERVICES BY:

Signature

Title

Printed Name

Date

PRA Disclosure Statement
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 0938-0832 (Expires XX/XX/20XX). This is a mandatory information collection.
The time required to complete this information collection is estimated to average 1 hour 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.

****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 CMS at [email protected].

Form CMS-1561 / OMB Approval Expires XX/XX/20XX

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