Health Insurance Benefit Agreement and Supporting Regulations (CMS-1561/1561A)

OMB 0938-0832

OMB 0938-0832

Applicants to the Medicare program are required to agree to provide services in accordance with Federal requirements. The CMS-1561 and 1561A are essential for CMS to ensure that applicants are in compliance with the requirements. Applicants will be required to sign the completed form and provide operational information to CMS to assure that they continue to meet the requirements after approval.

The latest form for Health Insurance Benefit Agreement and Supporting Regulations (CMS-1561/1561A) expires 2023-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form and Instruction
Supporting Statement A
All Historical Document Collections
 Reinstatement without change of a previously approved collection 2023-12-07
Approved with change
 Revision of a currently approved collection 2019-11-15
Comment filed on proposed rule and continue
 Revision of a currently approved collection 2019-08-21
Approved with change
 Extension without change of a currently approved collection 2017-07-12
Improperly submitted and continue
 Extension without change of a currently approved collection 2017-07-06
Approved without change
 Extension without change of a currently approved collection 2014-01-30
Approved with change
 Extension without change of a currently approved collection 2010-11-09
Approved without change
 Extension without change of a currently approved collection 2007-09-12
Approved with change
 Revision of a currently approved collection 2004-07-19
Approved without change
 New collection (Request for a new OMB Control Number) 2001-04-18
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