CLIA Laboratory User Fees

Description: Use this form to pay your CLIA fees.
Form Number: 35

CMS Freedom of Information Act (FOIA) Request Payment Form

Description: Please use this form to pay for CMS FOIA requests.
Form Number: CMS-633

CMS Health Insurance Marketplace and Premium Stabilization Programs Payment Form

Description: Please use this form to pay amounts owed related to the Health Insurance Marketplace and Premium Stabilization Programs. Additionally, if necessary, provide the following information to your bank to prevent debit blocking on the payments processed through Pay.gov on your dunning letter/invoice: ACH Company Name: USDEPTHHSCMS...Agency Company ID: 7505008014
Form Number: HHSCIIO
OMB Number: 0938-1187

CMS No Surprises Act Independent Dispute Resolution Form

Description: Use this form to pay your IDR invoice.
Form Number: No Surprises Act Independent Dispute Resolution (IDR)

Help Form

Form Number: Help

Long Term Care/COVID-19/HHA/CLIA Civil Money Penalty (CMP) Payment

Description: Use this form to pay Long-term care, COVID-19, HHA or CLIA Civil Money Penalty.
Form Number: CMS CMP

Medicare Coverage Gap Discount Program CMPs

Description: Please use this form to pay your Medicare Coverage Gap Discount Program Civil Monetary Penalties
Form Number: Medicare CGDP CMPs

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