Appendix A
Virtual Group Agreement Template
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 0938-1343. Expiration date: 01/31/2024. The time required to complete this information collection is estimated to average 10 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. *****CMS Disclaimer*****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 [email protected].
Sample Introductory Paragraph:
This Virtual Group Agreement (“Agreement”) is by and between Virtual Group Identifier provided by the Centers for Medicare & Medicaid Services, and XYZ Group Practice P.C. (“virtual group member”) and is effective [Month, Day, Year] (“Effective Date”).
<Body of Agreement>
Sample Signature Page:
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by the duly authorized representatives as of the dates below.
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
Virtual Group Member/National Provider Identifier
_________________________________________
Signature
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CMS-10652 PRA Appendix A - Virtual Group Agreement Template |
| Subject | CMS-10652 PRA Appendix A - Virtual Group Agreement Template |
| Author | HHS/CMS |
| File Modified | 0000-00-00 |
| File Created | 2024-08-31 |