Form CMS-20040: Regional Office Meeting / Speaker Request Form

Form CMS-20040 is the Regional Office Meeting / Speaker Request Form from the Centers for Medicare & Medicaid Services (CMS). It is a two-page request for CMS to take part in an event, with the CMS role picked from Speaker, Moderator/Panel, Exhibitor, Meeting Attendee or Other. The CMS forms page lists the OMB number as EXEMPT, and the form is printed CMS-20040 (12/05).

Page 1 asks for the event name, dates and time, full street address, sponsor and contact details, then an assessment of the CMS role, type of event, projected attendance, level of audience, media coverage, geographic breadth and special target areas. Page 2 asks for event languages, group affiliation, partners attending, media type, notes and a brief description of the event.

The instructions say to complete both pages and fax the form to the appropriate Regional Office, and page 1 lists a fax number for each of the 10 regions. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Form CMS-20040: Regional Office Meeting / Speaker Request Form, as printed by CMS

What's on Form CMS-20040

Event details

Event name, event dates and time, event location with the full street address required, sponsor name and type, contact name and title, and contact phone and email.

CMS role and type of event

The role asked of CMS, and the type of event: Education / Training, Meeting / Conference, Health Fair, State or Regional Media Interview, or Local Media Interview.

Attendance and audience

Projected attendance in ranges from 1 to 25 up to 300 or more, level of audience (Leaders, Mid level managers / coordinators, Front-line educators, Beneficiaries) and media coverage (National, Regional, Local).

Geographic breadth and target areas

Geographic breadth (Regional/National, State, County, Local) and special target areas, with all that apply indicated.

Event information on page 2

Event languages, ethnic or disability group affiliation, partners attending, media type, sponsor or attendee notes, and a brief description of the event such as its theme, political considerations or congressional interest.

CMS contact

The CMS initial contact, if one was already made, and a Date Received by CMS box.

The assessment choices on page 1 are circled or highlighted.

How to fill out Form CMS-20040

1
Describe the event
Enter the event name, dates and time, the full street address, the sponsor and the contact person's details.
2
Choose the assessment options
Circle or highlight the CMS role, type of event, projected attendance, level of audience, media coverage and geographic breadth, and every special target area that applies.
3
Complete page 2
Add the event languages, group affiliation, partners attending, media type, notes and a brief description of the event. Name the CMS initial contact if one was already made.
4
Fax it to the Regional Office
The instructions say to complete both pages and fax the form to the appropriate Regional Office. Page 1 lists the fax numbers.

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Regional Office fax numbers

Where to fax it

The form lists a fax number for each of the 10 CMS regional offices. Those numbers come from the 2005 edition of the form, so check the current contact details for your region on CMS.gov before you send it.

OMB status

The CMS forms page lists the OMB number for Form CMS-20040 as EXEMPT. The form does not list a fee or a deadline.

These are the fax numbers printed on the 12/05 form.

Who uses Form CMS-20040?

Event sponsors and contacts
The form asks for the sponsor name and type, and a contact name, title, phone and email for the event.
Events asking for a CMS speaker or panelist
The CMS Role choices are Speaker, Moderator/Panel, Exhibitor, Meeting Attendee and Other, with a note below for Other.
Media interview requests
The Type of Event choices include State or Regional Media Interview and Local Media Interview, and page 2 asks for the media type and the name of the outlet.
Events for specific audiences
The form asks for the level of audience and lets the requester indicate all special target areas that apply: Rural, Low-Income, Ethnic, Disability and Information Intermediary.

The form is a request from an event's sponsor or contact to a CMS Regional Office.

Official sources and the blank

Official CMS form page
The agency’s own page for Form CMS-20040.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form CMS-20040

What is Form CMS-20040?

It is the Regional Office Meeting / Speaker Request Form, a two-page request for CMS to take part in an event as a speaker, moderator or panelist, exhibitor, meeting attendee or in another role.

How is Form CMS-20040 sent?

The instructions say to complete both pages of the form and fax it to the appropriate Regional Office.

Which fax number should be used?

Page 1 lists a fax number for each of the 10 CMS Regional Offices, from Boston (Region 1) to Seattle (Region 10). The instructions say to send it to the appropriate Regional Office.

Is a full address needed for the event?

Yes. The Event Location field says the full street address is required.

What kinds of events does the form list?

Education / Training, Meeting / Conference, Health Fair, State or Regional Media Interview, and Local Media Interview.

How are the assessment choices marked?

The form says to circle or highlight them. For Special Target Area it says to indicate all that apply.

Form CMS-20040: Regional Office Meeting / Speaker Request Form