CENTERS FOR MEDICARE & MEDICAID SERVICES FREEDOM OF INFORMATION ACT REQUEST 1. CMS FOIA Request # 3. Date Received: 7. Requester: 8. Affiliation/Address: 9. Subject: 10. Referred To: 11. Category of Requester 4. Due Date: 2. Referring Regional Office #: 5. Response Date: 6. Processing Days: Commercial Educational/Scientific or News Media Other Yes No Circumvention of Agency Rules 12. IS THERE PROGRAM CONCERN ABOUT DISCLOSING THESE RECORDS? Ongoing Deliberation Decision-making process Proprietary Information Other (Specify) 13. ACTIONS: Direct Reply Not FOIA Fee Related Closure No Records Found Records Not Reasonably Described Direct Reply Invasion of Privacy Pending Litigation Open Investigation Request Withdrawn Subpoena Denial Other ACTUAL COSTS OF RESPONDING TO REQUEST 14. ACTUAL PROCESSING COSTS: Reading/Interpreting/Logging Clarifying/Negotiating/Consultation Searching for Records Review/Edit/Delete (DFOI Only) Compose/Type Response Other (specify) 15. COPYING COSTS � @ $.10 per page: Pages Located/Copied No. of Pages Released to Requester No. of Pages Sent to Next Review Level 16. MAILING COSTS: Postage Special Handling 18. Total Actual Cost: 19. Total Invoiceable Fees: 20. Fees Charged: 21. Fee Waived: 22. Name(s), Phone Number(s) and Component(s) of Person(s) Who Searched For and Compiled These Records: 23. Interim Reply Date(s): See reverse side for instructions on completing this form. If you have questions, call the Freedom of Information Group at (410) 786-5353. Form CMS-632 (03/13) American LegalNet, Inc. www.FormsWorkFlow.com Hours Hourly Wage Total 17. Invoiceable Fees xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx $ $ xxxxxxxxxxxxxxx $ No. of Pages No. of Sets Total 1 x $.10 per page 1 x $.10 per page xxxxxxxxxxxxxxx $_____________ xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx 1 INSTRUCTIONS FOR COMPLETING FORM CMS-632-FOI Completion of this form is mandatory. It must be attached to and remain with every Freedom of Information Act (FOIA) request for control and tracking. Every CMS employee involved in processing the request must add to a given Form CMS-632-FOI data accounting for that involvement. This data will be the base for the Annual Report. ITEM 1. CMS FOIA Request #: tracking number generated by the SWIFT system or the FOIA Contractor Portal. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Referring Regional Office #: referring regional office number. Date Received: date request was received in the FOIA unit. Due Date: date 20 working days from receipt of request in the FOIA unit. Response Date: actual date case was completed and response sent. Processing Days: the number of work days it took to process the request. Requester: last name, first name, initial of person who signed the request Affiliation/Address: name of company, law firm etc., and complete address of requester. Subject: explain briefly the nature of the request by subject or records requested. Referred To: where the request was sent for records search(es). Category of Requester: check appropriate category based upon number seven above. Actions: check all appropriate items that show the disposition of the request. Program Concern: check appropriate item(s) to show concern about release of these records. Actual Processing Costs: actual costs of time spent by each person involved in processing this request. Complete all items. Include computer-based data costs in the block entitled "other." Copying Costs: cost for photocopying the responsive records. Complete all applicable items. Copying cost are $.10 per page. Mailing Costs: input postage and special handling, such as certification of records. Total Actual Costs: summation of totals for actual processing, copying and mailing costs. Invoiceable Fees: different from actual costs. They are based upon the HHS fee schedule for search, review and copying activities. Total Invoiceable Fees: summation of search, review and copying fees. Fees charged: responding office tallies. If invoiceable fee is $25.00 or more, invoice the requester. Fees waived: If invoiceable fee is less than $25.00, do not invoice requester. Insert amount waived in this block. Name, Phone Number and Component of Person Who Searched For/Compiled Records: be specific;give name and title of person who searched, their component, address and phone number. Interim Reply Date(s): date(s) of response(s) that are not considered the final date of the Agency wide response to close the request. Form CMS-632 (03/13) American LegalNet, Inc. www.FormsWorkFlow.com