An attestation form for provider-based status documents the relationship between a main provider and its dependent facility. Healthcare facilities covered under 42 CFR 413.65 must demonstrate physical, financial, and operational integration to qualify for provider-based status and receive appropriate Medicare reimbursements.
The form covers several key compliance areas. Facilities must show they share governance, clinical operations, and financial reporting with the main provider. Hospitals, Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs) each follow distinct paths within CMS regulations, and the form reflects those differences.
Exclusions matter too. Ambulatory surgical centers and independent diagnostic testing facilities are not eligible for provider-based status under these rules. Understanding which entity types qualify can save significant time during the application process.
Submitting an accurate attestation form directly affects your facility's operational legitimacy and reimbursement rates under the Medicare program. The CMS review examines operational, clinical, and financial integrations in detail, so complete and accurate information is essential.
For related compliance documentation, see our compliance addendum form or explore CMS Form 1763 and CMS Form 40B for additional Medicare-related documentation.
| Question | Answer |
|---|---|
| Form Name | Attestation Form Sample |
| Form Length | 9 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min 15 sec |
| Other names | attestation form filled sample, filled attestation form sample, attestation how fill, printable attestation forms |