Centers For Medicare & Medicaid Services - Freedom Of Information Act Request
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1
2CENTERS FOR MEDICARE & MEDICAID SERVICES
FREEDOM OF INFORMATION ACT REQUEST
1. CMS FOIA Request #
2. Referring Regional Office #:
3. Date Received:
4. Due Date:
5. Response Date:
6. Processing Days:
7. Requester:
8. Affiliation/Address:
9. Subject:
10. Referred To:
11. Category of Requester
Commercial
Educational/Scientific or News Media
Other
12. IS THERE PROGRAM CONCERN ABOUT DISCLOSING THESE RECORDS?
Yes
No
Ongoing Deliberation
Invasion of Privacy
Circumvention of
Agency Rules
Decision-making process
Pending Litigation
Proprietary Information
Open Investigation
Other (Specify)
13. ACTIONS:
Direct Reply
No Records Found
Request Withdrawn
Not FOIA
Records Not Reasonably Described
Subpoena Denial
Fee Related Closure
Direct Reply
Other
ACTUAL COSTS OF RESPONDING TO REQUEST
Hours
Hourly Wage
Total
17. Invoiceable Fees
14. ACTUAL PROCESSING COSTS:
Reading/Interpreting/Logging
xxxxxxxxxxxxxxx
Clarifying/Negotiating/Consultation
xxxxxxxxxxxxxxx
$
Searching for Records
Review/Edit/Delete (DFOI Only)
$
Compose/Type Response
xxxxxxxxxxxxxxx
$
Other (specify)
15. COPYING COSTS – @ $.10 per page:
No. of Pages
No. of Sets
Total
Pages Located/Copied
1 x $.10 per page
xxxxxxxxxxxxxxx
No. of Pages Released to Requester
1 x $.10 per page
$_____________
No. of Pages Sent to Next Review Level
1
xxxxxxxxxxxxxxx
16. MAILING COSTS: Postage
xxxxxxxxxxxxxxx
Special Handling
18. Total Actual Cost:
19. Total Invoiceable Fees:
20. Fees Charged:
21. Fee Waived:
22. Name(s), Phone Number(s) and Component(s) of Person(s) Who Searched For and Compiled These Records:
23. Interim Reply Date(s):
See reverse side for instructions on completing this form. If you have questions, call the Freedom of Information Group at (410) 786-5353.
Form CMS-632 (03/13)
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