Form CMS-807 at a glance
What it is: Form CMS-807 (03/2024) is the Surveyor Notes Worksheet of the Centers for Medicare & Medicaid Services.
A filled-in Form CMS-807 example: a surveyor records one concern
How to fill out Form CMS-807, box by box
Facility Name
Enter the Facility Name.
Surveyor Name, Surveyor Number, Provider Number and Discipline
Enter the Surveyor Name, the Surveyor Number, the Provider Number and the Discipline.
Observation Dates
For Observation Dates, enter the From date and the To date, each as mm/dd/yyyy.
TAG/CONCERNS DOCUMENTATION
Under TAG/CONCERNS DOCUMENTATION, enter the tag or concern and its documentation.
Sources
[1] Form CMS-807 (03/2024), Surveyor Notes Worksheet, Centers for Medicare & Medicaid Services (the Official source link on this page).