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<br /> <br />40 <br />Revised 9/8/2021 <br />c. Contact information for the person submitting the e -mail – <br />Organization (Grantee), name, phone number and e -mail. <br />d. The document that needs to be put into an accessible for mat <br />shall be attached to the e-mail. <br />e. CMS may respond to the request and provide the <br />information directly to the requester. <br />iii. The Grantee shall maintain record of all alternate format requests received <br />including the requestor’s name, contact information, date of request, <br />document requested, format requested, date of acknowledgment, date <br />request provided, and date referred to CMS if applicable. Forward <br />quarterly records to the AltFormatRequest@cms.hhs.gov mailbox. <br />b. Services <br />i. When receiving a request for auxiliary aids and services (e.g., sign <br />language interpreter) from a beneficiary or member of the public, you <br />must: <br />1. Consider/evaluate the request according to civil rights laws. <br />2. Acknowledge receipt of the request and explain your process <br />within 2 business days. <br />3. Establish a mechanism to provide the request. <br />ii. If you are unable to fulfill an accessible service request, CMS may wor k <br />with you in an effort to provide the accessible service as funding and <br />resources allow. You shall refer the request to CMS within 3 business <br />days if unable to provide the service. You shall submit the request, using <br />encrypted e -mail (to safeguard any personally identifiable information), to <br />the AltFormatRequest@cms.hhs.gov mailbox with the following <br />information: <br />1. The e -mail title shall read “Grantee (Organization) Accessible <br />Service Request.” <br />2. The body of the e –mail shall include: <br />a. Requester’s name, phone number, e -mail, and mailing <br />address. <br />b. The type of service requested (e.g., sign language <br />interpreter and the type of sign language needed). <br />c. The date, time, address and duration of the needed service. <br />d. A description of the venue for which the service is needed <br />(e.g., public education seminar, one -on-one interview, etc.) <br />e. Contact information for the person submitting the e -mail – <br />Organization (Grantee), name, phone number and e -mail. <br />f. Any applicable documents shall be attached to the e -mail. <br />g. CMS will respond to the request and respond directly to the <br />requester. <br />iii. The Grantee shall maintain record of all accessible service requests <br />received including the requestor’s name, contact information, date of <br />request, service requested, date of acknowledgment, date service provided, <br />and date referred to CMS if applicable. Forward quarterly records to the <br />AltFormatRequest@cms.hhs.gov mailbox. <br />DocuSign Envelope ID: 7832B0E4-F34E-430E-A3C2-1A6A14F29307