Part I: Presenter details
Presenter's name, title, organizational affiliation with name, address, city and state, subject of the presentation, email address and telephone number.
CMS-20017
ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT
- Agency
- CMS
- Revision
- 04/17
- Fillable fields
- 22
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-20017: Advisory Panel on Hospital Outpatient Payment Presenter Checklist
Form CMS-20017 is the Presenter/Presentation Information Checklist for the Advisory Panel on Hospital Outpatient Payment (HOP Panel), from the Centers for Medicare & Medicaid Services. It is for people making a presentation at the panel meeting, which the form also calls the APC Panel. The CMS page lists the form as OMB Exempt.
Part I collects personal information for each presenter and a clear description of the action the presenter is asking CMS to take. Part II is a checklist of information that the form says has to appear on page 1 of the presentation, from financial relationships to the potential consequences of not making the change.
The form says to submit the checklist with the presentation to [email protected] by 5 p.m. on the date in the Federal Register notice, or as a hard copy if email is not possible. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-20017
Part I: Requested action
A box to clearly describe the action or actions the presenter is asking CMS to take.
Part II, items 1 to 3
Financial relationships of the presenters, if any, the CPT and HCPCS codes involved, and the APCs affected.
Part II, items 4 and 5
A description of the issue and a clinical description of the service under discussion, with a comparison to other services within the APC.
Part II, items 6 to 8
Recommendations and rationale for change, printed twice as items 6 and 7, and the potential consequences of not making the change.
How to submit Form CMS-20017
- 1
Find the deadline
The form says the checklist and presentation are due by 5 p.m. on the date specified in the Federal Register notice. The form itself does not print a date.
- 2
Complete Part I for each presenter
Enter each presenter's details and describe the action requested of CMS.
- 3
Work through the Part II checklist
Fill in each of the Part II items, from financial relationships to the consequences of not making the change.
- 4
Put the Part II information on page 1
The form says all Part II information has to be on page 1 of the presentation in a clear, logical format.
- 5
Send it with the presentation
Email the checklist, Parts I and II, with the presentation to [email protected], or mail a hard copy if email is not possible.
Why fill Form CMS-20017 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 when
By email
[email protected], with the checklist (Parts I and II) and the presentation.
By mail
If unable to submit by email, the form gives this address for a hard copy: Designated Federal Official, HOP Panel, CMS/CM/HAPG/DOC, 7500 Security Blvd., C4-01-26, Baltimore, Maryland 21244-1850.
Deadline
5 p.m. on the date specified in the Federal Register notice, according to the form.
Extra copies
The form points to https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20017.pdf to print another copy for more presenters.
Related forms
Who uses Form CMS-20017?
The form is for presenters at the Advisory Panel on Hospital Outpatient Payment meeting.
Official sources and the blank
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Questions about Form CMS-20017
Where do I send Form CMS-20017?
The form says to email the checklist with the presentation to [email protected]. If email is not possible, it gives a mailing address for the Designated Federal Official, HOP Panel, in Baltimore, Maryland.
What is the deadline for Form CMS-20017?
The form says 5 p.m. on the date specified in the Federal Register notice. It does not print a date itself.
What has to be on page 1 of the presentation?
The form says all the Part II information goes on page 1: financial relationships, CPT and HCPCS codes, APCs affected, a description of the issue, a clinical description of the service, recommendations with rationale, and the consequences of not making the change.
What if there are more than three presenters?
The form says to photocopy it or print another copy from the CMS download link.
Does the form ask about financial relationships?
Yes. Part II item 1 asks for the financial relationship of the presenters, if any, with any company whose products, services or procedures are under consideration.