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<br /> <br />42 <br />Revised 9/8/2021 <br />request, using encrypted e -mail (to safeguard any personally identifiable <br />information), to the AltFormatRequest@cms.hhs.gov mailbox with the <br />following 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 language requested. <br />c. The date, time, address and duration of the nee ded 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 alternate language service <br />requests received including the requestor’s name, contact information, <br />date of request, language requested, service requested, date of <br />acknowledgment, date service provided, and date referred to CMS if <br />applicable. Forward quarterly records to the <br />AltFormatRequest@cms.hhs.gov mailbox. <br /> <br />Please contact the CMS Office of Equal Opportunity and Civil Rights for <br />more information about accessibility reporting obligations at <br />AltFormatRequest@cms.hhs.gov. <br /> <br />DocuSign Envelope ID: 7832B0E4-F34E-430E-A3C2-1A6A14F29307