Form Cms-46 - Medicare Participating Physician And Supplier Agreement Page 2

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2
Received by
(name of carrier)
Effective date
Initials of carrier official
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0373. The time
required to complete this information collection is estimated to average 15 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have
any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-460 (10/05)

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