Name of the OPO
A line to insert the name of the facility, referred to in the rest of the agreement as the Organ Procurement Organization.
CMS-576A
Health Insurance Benefits Agreement with Organ Procurement Organization
- Agency
- CMS
- Revision
- 06/06
- Fillable fields
- 8
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-576A: Health Insurance Benefits Agreement with Organ Procurement Organization
Form CMS-576A is the Health Insurance Benefits Agreement with an Organ Procurement Organization (OPO), made under section 1138(b) of the Social Security Act, from the Centers for Medicare & Medicaid Services. The form says it is for the purpose of establishing eligibility under titles XVIII and XIX of the Act.
The one-page agreement names the OPO and lists six commitments, labeled A to F, covering compliance with the requirements and conditions it cites, cost reports, interim reimbursement rates, budget information, repayment of excess amounts and charges to individuals. It then says when the agreement becomes binding and effective, and has signature blocks for the OPO and for the Secretary of Health and Human Services.
The form carries OMB number 0938-0512 and estimates an average of 2 hours per response. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-576A
Item A: compliance
Maintain compliance with titles XVIII and XIX, section 1138 of the Act, 42 CFR Part 486 subpart G and approved Organ Procurement and Transplantation Network conditions, and report any failure promptly to CMS.
Items B to D: cost reporting
File a cost report under 42 CFR 413.24(f) within 5 months after the end of each fiscal year, let CMS designate an intermediary to set the interim rate, and provide budget or cost projection information.
Items E and F: payments and charges
Pay CMS amounts paid to transplant hospitals that are found to be above reasonable cost, and not charge individuals for items or services covered under section 1881.
Binding, termination and effective date
Paragraphs on when the agreement becomes binding, how it may be terminated, what happens on de-certification, and that it stays in effect as specified by 42 CFR 486.309.
Signatures
Name, title and date for the OPO and for the person accepting for the Secretary, plus the effective date of the agreement.
How to fill out Form CMS-576A
- 1
Insert the OPO name
Write the name of the Organ Procurement Organization on the line in the opening paragraph.
- 2
Read items A to F
Review the six commitments the OPO agrees to, including the cost report due within 5 months after the end of each fiscal year.
- 3
Sign for the OPO
The person signing for the Organ Procurement Organization enters their name, title and the date.
- 4
HHS acceptance
The second block is headed Accepted for Secretary of Health and Human Services By, followed by the effective date of the agreement. The form says the agreement becomes effective on the date the Secretary or Delegate specifies.
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What the agreement says
When it becomes binding
The form says the agreement is binding on the OPO and the Secretary upon submission by the OPO and acceptance for filing by the Secretary of Health and Human Services.
Termination
The form says either party may terminate the agreement in accordance with regulatory requirements, and it stays in effect as specified by 42 CFR 486.309 unless the OPO is de-certified.
Where it goes
The form does not print a submission address.
OMB number and time
The form shows OMB No. 0938-0512 and estimates an average of 2 hours per response. The CMS page lists an OMB expiration date of 2025-12-31.
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Who uses Form CMS-576A?
The agreement is between an Organ Procurement Organization and the Secretary of Health and Human Services.
Official sources and the blank
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Questions about Form CMS-576A
What is Form CMS-576A?
It is the Health Insurance Benefits Agreement with an Organ Procurement Organization under section 1138(b) of the Social Security Act, for establishing eligibility under titles XVIII and XIX of the Act.
When is the cost report due?
Item B says the OPO agrees to file a cost report in accordance with 42 CFR 413.24(f) within 5 months after the end of each fiscal year.
Who signs Form CMS-576A?
A person signs for the Organ Procurement Organization, and a second person accepts it for the Secretary of Health and Human Services. Each block has name, title and date.
When does the agreement take effect?
The form says it becomes effective on the date specified by the Secretary or his Delegate and stays in effect as specified by 42 CFR 486.309 unless the OPO is de-certified.
Can the agreement be ended?
The form says it may be terminated by either party in accordance with regulatory requirements.