Completing an attestation form correctly ensures your healthcare facility meets CMS provider-based status requirements. The steps below walk you through reviewing, editing, and submitting the completed form online.
Steps to complete your attestation form
- Download or open the form. Access the form using the button at the top of this page. It opens directly in your browser for immediate editing.
- Enter your facility information. Fill in the name, address, and type of your main provider. Include your National Provider Identifier (NPI) and the Medicare provider number assigned to your facility.
- Describe the integration criteria. Complete each section covering physical integration, financial integration, and clinical integration between your facility and the main provider. Attach supporting documentation where required.
- Identify the facility type. Indicate whether your facility is a hospital department, CAH, FQHC, RHC, or another eligible entity. Note any exclusions that apply, such as ambulatory surgical centers.
- Print on official letterhead and sign. Print the completed form on your main provider's official letterhead. Have an authorized representative sign where required.
- Submit to the correct parties. Send the form to your fiscal intermediary (FI) or Medicare Administrative Contractor (MAC). Mail a copy to your CMS Regional Office for their records.
Who needs an attestation form?
Provider-based attestation forms are required for a range of healthcare entities seeking to establish or maintain their provider-based status under CMS regulations. These include:
- Hospital departments and off-campus provider-based departments (PBDs)
- Critical Access Hospitals (CAHs) applying for specific department designations
- Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
- Healthcare facilities applying for the first time or renewing existing provider-based status
For related attestation documentation, see the certificate of attestation exemption form or the TennCare attestation form.
Frequently asked questions
What is the purpose of a provider-based attestation form?
The form allows healthcare facilities to formally attest to the CMS that they meet the criteria for provider-based status under 42 CFR 413.65. Approval grants the facility access to Medicare billing rules that apply to provider-based departments, including higher reimbursement rates and cost-sharing structures.
Where do I submit the attestation form?
Send the completed form to your fiscal intermediary (FI) or Medicare Administrative Contractor (MAC). Mail a copy to the CMS Regional Office that oversees your geographic area. Your MAC can provide the correct mailing address.
How long does CMS take to process the attestation?
Processing times vary. The CMS or MAC typically reviews attestation submissions within 30 to 90 days, though complex cases may take longer. Contact your MAC directly to track the status of your submission.
Can I use a digital signature on the attestation form?
CMS policy generally requires original signatures on attestation forms. Check with your MAC or fiscal intermediary before using a digital signature to confirm current requirements in your region.
Do I need a new attestation form every year?
An initial attestation is required when applying for provider-based status. Resubmission may be needed if there are material changes to the facility's structure, ownership, or operations. Consult your MAC for guidance on your specific situation.
For additional healthcare compliance forms, explore the MCCEE student attestation form or the California advance healthcare directive.