Provider name and D/B/A
The name of the provider, entered twice, and the business name of the provider (doing business as), if applicable.
CMS-1561
HEALTH INSURANCE BENEFIT AGREEMENT
- Agency
- CMS
- Revision
- 2025-12-01
- Fillable fields
- 14
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-1561: Health Insurance Benefit Agreement
Form CMS-1561 is the Health Insurance Benefit Agreement from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. Its subtitle calls it an agreement with a provider under section 1866 of the Social Security Act and 42 CFR Part 489. The agreement is between the Secretary of Health and Human Services and the named provider of services, which agrees to conform to section 1866 and applicable provisions in 42 CFR in order to receive payment under title XVIII of the Social Security Act.
The form says the agreement becomes binding on the provider and the Secretary once the provider submits acceptable assurance of compliance with title VI of the Civil Rights Act of 1964 and section 504 of the Rehabilitation Act of 1973, and the Secretary accepts it. It has signature blocks for the provider, for the Secretary and for a successor provider after a transfer of ownership.
The form shows OMB No. 0938-0832, with approval expiring 01/31/2027. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-1561
Agreement terms
To receive payment under title XVIII of the Social Security Act, the provider agrees to conform to section 1866 of the Act and applicable provisions in 42 CFR.
Civil rights assurance
The agreement becomes binding once the provider submits acceptable assurance of compliance with title VI of the Civil Rights Act of 1964 and section 504 of the Rehabilitation Act of 1973, and the Secretary accepts it.
Transfer of ownership
The agreement is automatically assigned to a new owner, including existing plans of correction and the duration of the agreement if it is time limited.
False statement notice
An attention notice quoting 18 U.S.C. section 1001, which says a person who knowingly and willfully falsifies a material fact shall be fined not more than $10,000 or imprisoned not more than 5 years or both.
Signature blocks
Signature, title, printed name and date for the provider of services, for the Secretary of Health and Human Services and for a successor provider of services.
The form is two pages: the agreement and provider signature on page 1, the other signature blocks and notices on page 2.
How Form CMS-1561 is filled out
- 1
Enter the provider's name
Type the provider's name in both spaces, and its business name after D/B/A if it has one.
- 2
Read the attention notice
The form asks the signer to read the provision of federal law on false statements, 18 U.S.C. section 1001, carefully before signing.
- 3
Sign for the provider
The person accepting for the provider of services signs and adds a title, printed name and date on page 1.
- 4
Secretary's acceptance
The block on page 2 headed Accepted by the Secretary of Health and Human Services holds the Secretary's signature, title, printed name and date.
- 5
Successor provider block
After a transfer of ownership, the successor provider of services signs the block at the bottom of page 2 with a title, printed name and date.
- 6
Ask where to send it
The form prints no submission address. It says questions about where to submit documents go to your Medicare Administrative Contractor (MAC) or State Survey Agency.
Why fill Form CMS-1561 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what the form says
Where to send it
The form does not print a submission address. Its CMS Disclosure says to contact your respective Medicare Administrative Contractor (MAC) or State Survey Agency with questions about where to submit documents.
Not to the PRA office
The form says not to send applications, claims, payments, medical records or other documents with sensitive information to the PRA Reports Clearance Office. That CMS address in Baltimore is for comments on the time estimate.
When it becomes binding
The form says the agreement is binding on the provider and the Secretary after the provider submits acceptable assurance of civil rights compliance and the Secretary accepts it.
Time to complete
The form estimates an average of 1 hour per response and calls it a mandatory information collection. It shows OMB No. 0938-0832, expiring 01/31/2027.
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Who uses Form CMS-1561?
The agreement is between the Secretary of Health and Human Services and a provider of services.
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Questions about Form CMS-1561
What is Form CMS-1561?
It is the Health Insurance Benefit Agreement, an agreement between the Secretary of Health and Human Services and a provider of services under section 1866 of the Social Security Act and 42 CFR Part 489.
Why does a provider sign Form CMS-1561?
The form says the provider signs it in order to receive payment under title XVIII of the Social Security Act, and agrees to conform to section 1866 of the Act and applicable provisions in 42 CFR.
When does the agreement become binding?
The form says it is binding on the provider and the Secretary once the provider submits acceptable assurance of compliance with title VI of the Civil Rights Act of 1964 and section 504 of the Rehabilitation Act of 1973, and the Secretary accepts it.
What happens to the agreement on a transfer of ownership?
The form says it is automatically assigned to the new owner, subject to its conditions and 42 CFR 489, including existing plans of correction and the agreement's duration if it is time limited. Page 2 has a block for the successor provider.
Where is Form CMS-1561 sent?
The form prints no submission address. It says to contact your Medicare Administrative Contractor (MAC) or State Survey Agency with questions about where to submit documents.
How long does Form CMS-1561 take to complete?
The form estimates an average of 1 hour per response, including the time to review instructions, search existing data resources and gather the data needed.