Form Cms-633 - Invoice Of Fees For Foia Services
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1
2important: return a copy of this invoice with remittance
invoice of fees for foia services
*
caSe number
date
materiaL reQueSted
name of reQueStor
organization
Street addreSS
city
zip code
State
numBer
numBer
reproduction
each page 10 ¢
other
(e.g. computer printout)
search fees; per hour (Based on salary of searcher as per 45 cfr 5.43)
LeveL 1
LeveL 2
LeveL 3
review fees; per hour (Based on salary of reviewer as per 45 cfr 5.43)
LeveL 1
LeveL 2
LeveL 3
special services;
certification ($10.00)
return receipt ($2.15)
other
pay total of
$
Questions regarding enclosed material or charges, call:
make check or money order payabLe to: centerS for medicare & medicaid
ServiceS and remit with a copy of thiS invoice to:
centerS for medicare & medicaid ServiceS
diviSion of accounting
p.o. box 7520
baLtimore, md 21207-0520
*please include the case numBer on your check or money order
enclosed is payment of $
by check
money order
form cmS-633 (01/08)
see reverse side
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Parent category: Medical