CMS/Freedom of Information Act (FOIA) Document/Records Request Form
Use this form to request records that are not already available within the
public domain.
- You may print this form, complete it, sign it and
either mail or fax it to CMS' Freedom of Information Group to the address
or facsimile number listed at the end of this form. This form cannot be
electronically transmitted to this agency via the Internet.
- You are not required to use this form, a request can be written on personal
or business letterhead or on plain bond paper. The form is offered as a
courtesy and/or as a guide to assist you in providing a perfected FOIA
request.
Do not use this form to request documents believed to be housed in a library or
research facility. Do not use this form to request records that can be obtained
from the Government Printing Office, National Technical Information Service, or
that were created for publication. See HHS Regulation 45 CFR Part 5.
Requester Identification Data
Your Name: __________________________________________________
Your Title: _________________________________________________
Your Organization's Name: ___________________________________
Your Address:__________________________________________________
______________________________________________________________
City: __________________ State: _______________ Zip: __________
Telephone: _____________________ Alternate telephone #:
_______________________
(Note: FOIA requests are not accepted via telephone. We may, however, need to
contact you to discuss your request.
FAX: (Optional) ________________________________ (Note: Signed FOIA requests
are accepted via facsimile transmissions. We do not, however, provide final
responses via facsimile transmissions due to internal administrative processing
requirements.
Documents Requested:
- Please list, as clearly as possible, the name of the
document(s), the type of document(s)*, date of or date range of the
document(s) and any other specifics you may have that will identify the
records you seek. *(For example: letters, memoranda, reports, contracts,
proposals, etc.)
- If you seek records that concern a specific geographic
region of the United States, or that you believe are located in a specific
geographic region of the United States, please so advise.
- If you seek records on an individual other than yourself, please provide a
signed authorization document, signed by the subject of the records. Please see the attached consent form requirements
listing.
- If you seek records on yourself, no authorization form is required.
Note:
- You are entitled to request as many types of records
and items as you wish, the number of items you may request is not limited to
the number of items listed on this form.
- You may submit as many FOIA requests as you desire.
- You are not required to request more than one item.
List your requested items below:
Item #:
Description of records requested
1
_______________________________________________________________________________
2
_______________________________________________________________________________
3
_______________________________________________________________________________
4
_______________________________________________________________________________
5
_______________________________________________________________________________
6
_______________________________________________________________________________
7
_______________________________________________________________________________
8
_______________________________________________________________________________
9
_______________________________________________________________________________
10
_______________________________________________________________________________
Expedite of a FOIA request:
CMS has 20 working days in which to respond to your request. If you have an
urgent matter involving your request, please provide details. On a case by case
basis, some "Media" requests may qualify for expedited processing.
There are 3 major "requester circumstances" for which this agency can
expedite the processing of your request. They are:
- If there are Health and Safety issues involved.
- If you need the records in order to respond to a
proposed regulation issued by this Agency.
- If you are in need of the records to respond to a hearing or administrative
tribunal.
If you believe your request qualifies for expedited processing, please
provide details and send a copy of the court scheduling order.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Fees:
Fees may be assessed for processing your request and an invoice for those fees
may be issued with our final response to you as set forth in HHS Regulations 45
CFR Part 5.
- If you have a dollar limit on how much you are at
liberty to pay, please list that fee limit: ________________________.
- NOTE: If the cost to 1) search for the records you
requested, 2) copy the records you requested and/or 3) review the records you
requested is estimated to exceed your limit, CMS staff will contact you to
discuss before mailing the records or an invoice to you.
- If you set no limit, and if the cost to search, copy and/or review the
records you requested exceed $250, CMS staff will contact you to request that
the amount of the estimated fees be provided to CMS before we proceed with
further processing of your request.
Fee Waivers:
Fee Waivers or a reduction of fees may be granted under certain circumstances
as set forth in HHS Regulations 45 CFR Part 5.
* If your request appears to meet both tests as listed below, CMS staff will
contact you for further information to determine a final conclusion. Please
explain how your request complies with the following:
I. Disclosure of the information is in the public interest because it is likely
to contribute significantly to the public understanding of the operations or
activities of government.
If so, please explain:
______________________________________________________________
______________________________________________________________________________
II. Disclosure of the information is not primarily in the commercial interest
of the requester.
If so, please explain:
______________________________________________________________
______________________________________________________________________________
_____________________
Date of Signature
____________________________________
Signature of Requester
Mail or Fax this request to
FAX: 410-786-0474
Centers for Medicare & Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Freedom of Information Group
Room N2-20-16
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Questions or comments concerning this form can be directed to the
FIG Office Support Staff (410) 786-5353.
Last Modified on Thursday, September 16, 2004
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