Form CMS-671 at a glance
What it is: This form, the Long-term care facility application for Medicare and Medicaid, is to be completed by the Facility.
For the purpose of this form, "the facility" equals certified beds (i.e., Medicare and/or Medicaid certified beds).
A filled-in Form CMS-671 example: an initial application for a facility owned by a corporation
How to fill out Form CMS-671, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Name of Facility, Provider Number, Fiscal Year Ending
Write the Name of Facility and the Fiscal Year Ending F5 (mm/dd/yyyy). This includes components or units of a larger institution. On all recertifications, insert the facility's assigned six- digit provider code in Provider Number.
Street Address and City
Write the Street Address: street name and number refers to physical location, not mailing address, if two addresses differ. For the City, rural addresses should include the city of the nearest post office.
County, State, Zip Code
Write the County: county refers to parish name in Louisiana and township name where appropriate in the New England States. Write the State: for U.S. possessions and trust territories, name is included in lieu of the State. Write the Zip Code: Zip Code refers to the "Zip-plus-four" code, if available, otherwise the standard Zip Code.
Telephone Number
Write the F6: Telephone Number: include the area code.
Medicare, Medicaid, Other, Total Residents
Enter F8a Medicare: residents whose stay is covered by their Medicare Part A Skilled Nursing Facility (SNF) benefit (primary payer is Original Medicare or a Medicare Advantage (Part C) plan). Enter F8b Medicaid: residents whose stay is covered by a state's Nursing Facility (NF) benefit (primary payer is Medicaid or Medicaid Managed Care). Enter F8c Other: residents for whom a bed is maintained on the day the survey begins, including those temporarily away in a hospital or on leave. This should be representative of residents in the nursing facility or those who have a bed-hold. Enter F8d Total Residents.
Skilled Nursing Facility (SNF), Nursing Facility (NF), SNF/NF
In F9 enter either 01 (SNF), 02 (NF), or 03 (SNF/NF): 01 Skilled Nursing Facility (SNF) - Medicare Participation, 02 Nursing Facility (NF) - Medicaid Participation, 03 SNF/NF - Medicare/Medicaid.
Hospital based
For F10, Is this facility hospital based: if the facility is under administrative control of a hospital, check "yes," otherwise check "no." If yes, indicate the Hospital Provider Number F11: the hospital provider number is the hospital's assigned six-digit Medicare provider number.
Ownership
For F12, Ownership, identify the type of organization that controls and operates the facility and enter the code as identified for that organization. Definitions to Determine Ownership are: For-Profit, if operated under commercial ownership, indicate whether owned by individual, partnership, corporation, or limited liability corporation (LLC); Non-Profit, if operated under voluntary or other nonprofit auspices, indicate whether church related, nonprofit corporation or other nonprofit; Government, if operated by a governmental entity, indicate whether State, City, Hospital District, County, City/County, or Federal Government.
Multi-Facility Organization
For F13, Owned or leased by Multi-Facility Organization, check "yes" if the facility is owned or leased by a multi-facility organization, otherwise check "no." A Multi-Facility Organization is an organization that owns two or more long term care facilities. The owner may be an individual or a corporation. Leasing of facilities by corporate chains is included in this definition.
For F14, if applicable, enter the name of the multi-facility organization. Use the name of the corporate ownership of the multi-facility organization.
Dedicated Special Care Units
For Dedicated Special Care Units, show the number of beds for all that apply. Enter the number of beds in the facility's Dedicated Special Care Units in F15 - F23. These are units with a specific number of beds, identified and dedicated by the facility for residents with specific needs/diagnoses. They need not be certified or recognized by regulatory authorities. For example, a SNF admits a large number of residents with head injuries. They have set aside 8 beds on the north wing, staffed with specifically trained personnel. Show "8" in F19.
Organized groups of residents and family members
For F24, check "yes" if the facility currently has an organized residents' group, i.e., a group(s) that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; to support each other; to plan resident and family activities; to participate in educational activities or for any other purposes; otherwise check "no."
For F25, check yes or no: Does the facility currently have an organized group of family members of residents?
Experimental research and CCRC
For F26, check "yes" if the facility conducts experimental research; otherwise check "no." Experimental research means using residents to develop and test clinical treatments, such as a new drug or therapy, that involves treatment and control groups. For example, a clinical trial of a new drug would be experimental research.
For F27, check "yes" if the facility is part of a continuing care retirement community (CCRC); otherwise check "no." A CCRC is any facility which operates under State regulation as a continuing care retirement community.
Waiver of seven day RN requirement, Waiver of 24 hr licensed nursing requirement
If the facility currently has a staffing waiver, indicate the type(s) of waiver(s) by writing in the date(s) of last approval. Indicate the number of hours waived for each type of waiver granted. If the facility has been granted a nurse staffing waiver by CMS or the State Agency in accordance with the provisions at 42CFR 483.35(e) or (f), enter the last approval date of the waiver(s) and report the number of hours being waived for each type of waiver approval. Waiver of seven day RN requirement: write F28: Date (mm/dd/yyyy) and F29: Hours waived per week. Waiver of 24 hr licensed nursing requirement: write F30: Date (mm/dd/yyyy) and F31: Hours waived per week. If the facility does not have a waiver, write NA in the blanks.
Nurse Aide Training and Competency Evaluation Program
For F32, check "yes" if the facility has a State approved Nurse Aide Training and Competency Evaluation Program; otherwise check "no."
Sign
This form is to be completed by the Facility: write the Name of Person Completing Form and the Time, sign on the Signature line, and write the Date.
Common questions about Form CMS-671
What is a CMS 671?
This form, the Long-term care facility application for Medicare and Medicaid, is to be completed by the Facility.
Sources
[1] Form CMS-671 (09/2023), Long-term Care Facility Application for Medicare and Medicaid, Department of Health and Human Services Centers for Medicare & Medicaid Services (the Official source link on this page).
