Form Cms 417 PDF Details

Navigating the paths of healthcare compliance and certification can often present as a complex journey, detailed with requirements that ensure the provision of high-quality care to those in need. At the forefront of such regulatory frameworks for hospices seeking to offer services to Medicare beneficiaries is the CMS-417 form, a crucial document sanctioned by the Department of Health and Human Services and operatively managed by the Centers for Medicare & Medicaid Services (CMS). Designed with a dual purpose, this form not only facilitates the collection of essential information regarding the hospice for scheduling a proper state survey but also creates a database that addresses inquiries from Congress, federal agencies, and the public. Healthcare entities must complete this form to initiate the certification process in the Medicare program, thereby establishing their eligibility to provide hospice benefits. It incorporates a spectrum of details from identifying information, such as the Medicare certification number and type of hospice, to the variety of services provided and the structure of control, whether non-profit, proprietary, or government-owned. Prospective applicants are advised to answer comprehensively, understanding that both direct and arranged services must be documented accurately. Moreover, the form cautions against false statements, highlighting the legal implications and the potential for denial or termination of certification. With mandatory completion directed towards the applicable State Agency, the CMS-417 form positions itself as a pivotal first step for hospices aspiring to deliver care under the Medicare umbrella.

QuestionAnswer
Form NameForm Cms 417
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescms 417 forms download, hospice request certification medicare, cms 417 program pdf, cms form 417

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

OMB No.0938-0313

CENTERS FOR MEDICARE & MEDICAID SERVICES

 

 

 

 

 

INSTRUCTIONS FOR COMPLETING HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM

STATEMENT CONCERNING INFORMATION COLLECTION REQUIREMENTS AND USES:

This form is required to obtain or retain Medicare benefits. It serves two purposes. First, it provides basic information about the Hospice which is necessary for the State to properly schedule a survey. Second, it provides a data-base necessary for responding to questions frequently asked by Congress, Federal agencies, and interested members of the public.

Submission of this form will initiate the process of obtaining a decision as to whether the Conditions are met.

Answer all questions as of the current date. Complete and return this form to your State Agency (found at https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/downloads/state_agency_contacts.pdf), and retain a copy for your files.

Detailed instructions are given for questions other than those considered self-explanatory.

ITEM I:

Request to establish eligibility in—current Hospice Benefits are available only through the Medicare program.

Medicare certification number:

Insert the facility’s six digit Medicare Certification Number. Leave blank on initial requests for certification.

State/County and State/Region Codes:

Leave blank. The Centers for Medicare & Medicaid Services Regional Office will complete.

Related certification number:

If Hospice is affiliated with any other type Medicare provider, insert the related facility’s six digit Medicare Certification Number.

ITEM IV:

If a service is provided directly by the facility place a “1” the appropriate block.

If a service is provided through an outside source (i.e., by contract/arrangement), place a “2” in the appropriate block.

If a service is provided both directly and through arrangement, place a “3” in the appropriate box.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0313. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0313

 

 

HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM

(Read Instructions and Information Collection Statement On Cover Sheet of Form Prior to Completion)

 

Name of Hospice

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

I. Identifying Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Request to Establish Eligibility In

 

 

 

City, County and State

 

 

 

 

Zip Code

 

 

 

 

1.

Medicare

 

 

 

 

PH1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare/Certification Number

 

State/County

State/Region

 

 

Telephone Number

 

 

Related Certification Number

 

 

 

 

 

 

 

 

 

 

 

 

(INCLUDE AREA CODE)

 

 

 

 

 

 

 

 

 

 

PH2

 

 

PH3

 

 

 

PH4

 

 

 

 

PH5

 

 

 

 

PH6

II. Type of Hospice

1.

Hospital

 

 

 

 

 

For Hospitals Only (CHECK ONE)

 

 

 

 

Fiscal Year Ending Date

 

(CHECK ONE)

 

 

 

 

 

A.

The Joint Commission Accredited

 

 

 

 

 

 

 

2.

Skilled Nursing Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

AOA Accredited

 

 

 

 

 

 

 

 

 

 

3.

Intermediate Care Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Both The Joint Commission and AOA Accredited

 

 

 

 

 

 

 

4.

Home Health Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

Non-Accredited

 

 

 

 

 

 

 

 

 

PH7

5.

Freestanding Hospice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. Type of Control

Non-Profit:

 

 

Proprietary:

 

Government:

 

 

 

 

 

 

 

 

 

(CHECK ONE)

1.

Church

 

 

4.

Individual

 

8.

State

 

 

12.

Combination Government

 

 

2.

Private

 

 

5.

Partnership

 

9.

County

 

 

 

and Nonprofit

 

 

3.

Other

 

 

6.

Corporation

 

10.

City

 

 

13.

Other

 

 

 

PH8

 

 

 

 

7.

Other

 

11.

City-County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV. Services Provided:

Core:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By staff, place a “1” in the

1.

Physician Services

 

2.

Nursing Services

 

3.

Medical Social Services

4.

Counseling Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

block(s)

5.

Physical Therapy

 

 

 

 

Name and Address of Contractee

 

Medicare Certification/Supplier Number

 

If under arrangement,

6.

Occupational Therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

place a “2” in the block(s)

7.

Speech-Language Pathology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Hospice Aide

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If by staff and arrangement,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Homemaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

place a “3” in the block(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Medical Supplies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Short Term lnpatient Care

PH1O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Other(Specify)

 

A. ______Acute

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PH9

 

 

 

 

B. ______Respite

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. Number of Employees/

Physicians

 

Registered Professional Nurses

Licensed Practical Nurses/

Medical Social Workers

 

Total Number

 

Volunteers Full-time

 

 

PH11

 

 

 

PH12

Licensed Vocational Nurses PH13

 

 

 

 

PH14

 

 

 

 

Equivalent

Employees

Volunteers

Employees

 

Volunteers

 

Employees

 

Volunteers

Employees

 

Volunteers

 

 

 

 

A.

 

B.

A.

 

 

B.

 

A.

 

B.

A.

 

B.

 

 

 

 

Top section of professional

 

 

 

 

 

 

 

 

 

PH19

Homemakers

 

Hospice Aide

 

Counselors

 

 

 

Others

 

 

 

 

 

 

 

category reflects total

 

 

 

 

 

 

 

 

 

Employees

 

Volunteers

 

 

PH15

 

 

 

PH16

 

 

 

PH17

 

 

 

 

PH18

 

 

number of FTE (i.e., PH 11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employees

Volunteers

Employees

 

Volunteers

 

Employees

 

Volunteers

Employees

 

Volunteers

 

 

 

 

through PH 18)

 

 

 

 

 

 

 

 

A.

 

B.

A.

 

 

B.

 

A.

 

B.

A.

 

B.

 

A.

 

B.

 

 

 

 

 

 

 

 

 

Whoever knowingly or willfully makes or causes to be made a false statement or representation on this form may be prosecuted under applicable Federal or State laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate, or where the entity already participates, a termination of its agreement or contract with the State agency or the Secretary as appropriate.

Name of Authorized Representative and Title (Typed)

Signature

Date

 

 

PH20

Form CMS-417 (12/15)

 

 

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Tips to complete cms417 portion 1

2. Once the previous segment is done, you'll want to include the needed details in By staff place a in the blocks If, Physical Therapy Occupational, Medical Supplies, Short Term lnpatient Care, PHO, A Acute B Respite, V Number of Employees, Volunteers Fulltime Equivalent Top, Physicians, Registered Professional Nurses PH, Employees, Volunteers, Employees, Volunteers, and Licensed Practical Nurses Licensed so that you can go further.

Stage no. 2 of submitting cms417

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