Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 5/2/2006
Regional Office Meeting-Speaker Request Form {CMS-20040}
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Description
Regional Office Meeting / Speaker Request Form Instructions: Complete both pages of this form, and fax it to the appropriate Regional Office. FAX Numbers Boston Regional Office (Region 1): New York Regional Office (Region 2): Philadelphia Regional Office (Region 3): Atlanta Regional Office (Region 4): Chicago Regional Office (Region 5): 617-565-1339 212-264-6189 215-861-4140 404-562-7162 312-353-0252 Dallas Regional Office (Region 6): Kansas City Regional Office (Region 7): Denver Regional Office (Region 8): San Francisco Regional Office (Region 9): Seattle Regional Office (Region 10): Event Location (full street address required): Sponsor Name / Type: Contact Phone / e-mail: Speaker Education / Training Moderator/Panel Meeting / Conference 100-149 200-249 150-199 Mid level managers / coordinators Regional State Exhibitor Health Fair Meeting Attendee State or Regional Media Interview 26-49 Beneficiaries Other (note below) Local Media Interview 214-767-6400 816-426-3548 303-844-6374 415-744-3517 206-615-2027 Event Name: Event Date(s) / Time: Contact Name / Title: Assessment (please circle or highlight) CMS Role: Type of Event: Projected Attendance: Level of Audience: Media Coverage: Geographic Breadth: Special Target Area: (indicate ALL that apply) Leaders National Regional/National 250-299 300+ 50-74 75-99 Front-line educators Local County Local 1-25 Rural Low-Income Ethnic Disability Information Intermediary CMS-20040 (12/05) EF 12/2005 American LegalNet, Inc. www.USCourtForms.com Regional Office Meeting / Speaker Request Form Event Information Event Language(s): Partners Attending: Media Type: (print /electronic, name of outlet) Sponsor / Attendee Notes: (other pertinent Information) Brief Description of Event: (e.g., theme, political considerations, congressional interest, other pertinent info.) CMS Initial Contact: (If already made) Date Received by CMS: Ethnic / Disability Group Affiliation: CMS-20040 (12/05) American LegalNet, Inc. www.USCourtForms.com
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