Clinic name and purpose
A blank for the name of the Rural Health Clinic, and the statement that the agreement is for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act.
CMS-1561A
HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC
- Agency
- CMS
- Revision
- 12/2025
- Fillable fields
- 9
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-1561A: Health Insurance Benefits Agreement with a Rural Health Clinic
Form CMS-1561A is the Health Insurance Benefits Agreement for a Rural Health Clinic, 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 Rural Health Clinic pursuant to Section 1861(aa)(2)(K)(ii) of the Social Security Act, made for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act.
The first page has a blank for the clinic's name and five agreements, lettered A to E: keeping compliance with the conditions for certification in 42 CFR part 491, limits on charging beneficiaries, refunds of money collected incorrectly, accepting beneficiaries for care, and accepting additional provisions the Secretary finds necessary. It also covers the effective date, termination and transfer of ownership, and quotes the federal false statements law.
The second page has two signature blocks, one for the Rural Health Clinic and one for the Secretary of Health & Human Services. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-1561A
Agreements A and B
A: maintain compliance with the conditions for certification in 42 CFR part 491 and promptly report any failure to CMS. B: not charge the beneficiary or any other person for items and services covered under 42 CFR part 405, except deductible or coinsurance amounts under §405.2410.
Agreements C to E
C: refund as promptly as possible any money incorrectly collected from a beneficiary. D: accept beneficiaries for care and treatment without limitations, except those imposed on all other persons. E: accept any additional provisions the Secretary finds necessary or desirable for the Medicare program.
Effective date, termination and ownership
The agreement is binding once submitted by the clinic and accepted for filing by the Secretary, takes effect on the date the Secretary or delegate specifies, and either party may end it in accordance with regulations.
Federal law notice
An ATTENTION block quotes 18 U.S.C. section 1001 on false statements, with a fine of not more than $10,000, imprisonment of not more than 5 years, or both.
Signature blocks
Page 2 has Accepted for Rural Health Clinic By and Accepted for Secretary of Health & Human Services By, each with signature, title, printed name and date.
The form has two pages.
How Form CMS-1561A is completed
- 1
Enter the clinic's name
Write the name of the Rural Health Clinic in the blank at the top of page 1.
- 2
Read the agreements
Read agreements A to E and the paragraphs on effective date, termination and transfer of ownership.
- 3
Read the federal law provision
The form says to read the 18 U.S.C. section 1001 provision carefully before signing.
- 4
Sign for the clinic
Fill in the Accepted for Rural Health Clinic By block with a signature, title, printed name and date.
- 5
Leave the HHS block
The Accepted for Secretary of Health & Human Services By block is completed on the Secretary's side when the agreement is accepted.
Why fill Form CMS-1561A 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, term and OMB notice
Where to send it
The form does not print a submission address. Its CMS Disclosure says questions about where to submit documents go to your respective Medicare Administrative Contractor (MAC) or CMS Survey Operations Group Location.
Not to the PRA office
The form says not to send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.
Effective date
The agreement takes effect on the date specified by the Secretary or the Secretary's delegate and remains in effect unless terminated.
Termination
Either party may terminate it in accordance with regulations. The form says payment is not available for Rural Health Clinic services furnished on or after the effective date of termination.
OMB number and time
OMB No. 0938-0832, approval expires 01/31/2027. The form calls it a mandatory information collection and estimates an average of 1 hour per response.
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Who uses Form CMS-1561A?
The form is an agreement between a Rural Health Clinic and the Secretary of Health and Human Services.
Official sources and the blank
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Questions about Form CMS-1561A
Who signs Form CMS-1561A?
Page 2 has two blocks: Accepted for Rural Health Clinic By, and Accepted for Secretary of Health & Human Services By. Each asks for a signature, title, printed name and date.
When does the agreement take effect?
The form says it is binding once submitted by the clinic and accepted for filing by the Secretary, and takes effect on the date the Secretary or the Secretary's delegate specifies.
What happens to the agreement if the clinic changes owners?
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 duration of the agreement if it is time limited.
Where is Form CMS-1561A submitted?
No address is printed on the form. Its CMS Disclosure says to contact your respective Medicare Administrative Contractor (MAC) or CMS Survey Operations Group Location with questions about where to submit documents.
Can the agreement be ended?
Yes. The form says either party may terminate it in accordance with regulations, and payment is not available for services furnished on or after the effective date of termination.
How long does Form CMS-1561A take to complete?
The Paperwork Reduction Act statement estimates an average of 1 hour per response, including the time to review instructions and gather the data needed.