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 refer to the consent form requirements listing.
• If you seek records on yourself, no authorization form is required.

Notes:

1. 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.
2. You may submit as many FOIA requests as you desire.
3. 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:

1. If there are Health and Safety issues involved.
2. If you need the records in order to respond to a proposed regulation issued by this Agency.
3. 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.

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Page Last Modified: 12/14/2005 12:00:00 AM
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