Notice_of_Corrective_Action_Select_One_Mitigating_Factors_Affirmative_Defenses_Waiver_Support_Approval_508

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-17
Baltimore, Maryland 21244-1850
Notice of Corrective Action (Select One: Mitigating Factors, Affirmative Defenses, Waiver
Support) Approval
Date of Notice: FULL DATE
CONTACT NAME
JOB TITLE
CE NAME
ADDRESS 1
ADDRESS 2
CITY, ST ZIP
Re: Corrective Action Number XXXXX
Dear TITLE LAST NAME:
On (month, day, year), submitted (insert all that apply: mitigating
factors, affirmative defenses, or waiver support) in response to the results of the 2024 corrective
action.
We have reviewed and approved the (insert all that apply: mitigating
factors, affirmative defenses, or waiver support). All Civil Money Penalties (CMP) actions will
be suspended at this time; however, your record will remain in a pending status until the
violations have been corrected. We will follow up with you periodically and request a Corrective
Action Plan (CAP) status update. We expect your full cooperation and that will correct all violations.
If you have any questions about this letter, please contact (contact name) at
[email protected], or 555-555-5555. When contacting this office, please include the
corrective action number located at the top of this letter.

Sincerely,
Michael Cimmino, Director
National Standards Group
Office of Burden Reduction and Health Informatics
cc:
Contact Name
In accordance with the Paperwork Reduction Act (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-XXXX (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average
[10 hours] per response (4 forms x 60 minutes/form), 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:
Centers for Medicare & Medicaid Services
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. 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: Kevin Stewart at [email protected] .