Instructions for Completion of Form CMS-1521 - (Rev. 5, 08-30-

70.1 - Instructions for Completion of Form CMS-1521 - (Rev. 5, 08-30- 02) A1-1410.1, B1-4410.1 Data comes from Treasury Form FMS-5401 Payment Voucher. Date drawn - Contractor enters the date funds were drawn. It shall use 2 digits. Voucher Number - Contractor enters the payment voucher number in 3 digits beginning with voucher number 001 to 999. It shall inform the bank to start over when number 999 is reached. Serial Number - Contractor enters the serial number of the payment voucher. Hospital Insurance Benefits - Contractor enters the total amount drawn for HI and SMI. The total of HI and SMI benefits should equal the total funds drawn. NOTE: Part B contractors enter amounts for SMI only. PMS Smartlink Communication System for Administrative Costs – On pages 1 and 2, the contractor shall continue to report administrative costs drawn via the PMS Smartlink Telecommunications System in the same designated "Administrative Cost" column 4. However, it shall show these amounts after it reports all benefit payment amounts. Contractor shall indicate in the "date drawn" column the date the money was deposited into its commercial bank account and not the date it requested the money. This entry (entries) may occur on either page 1 or 2 depending on the number of entries. Contractor shall not make entries in the columns for Voucher Number, Serial Number, and Voucher Totals. Contractor shall reflect the current or prior year administrative costs drawn via Smartlink. It shall report on page 3 any special project(s) amount(s) drawn via Smartlink. Public reporting burden for collecting this information is estimated to average 1 hour per response. This includes time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Contractor shall send comments regarding this estimated burden or any other suggestions for reducing the burden to: Office of Management and Budget Paperwork Reduction Project (0938-0361) Washington, D.C. 20503; and to: Centers for Medicare & Medicaid Services Office of Financial Operations 7500 Security Boulevard Baltimore, Maryland 21244-1850.