Form Hea 5801 PDF Details

In October of 2016, the Centers for Medicare and Medicaid Services (CMS) released a new version of Form Hea 5801, the Request for Determination of Medicare Coverage (RFDMC). This form is used to request coverage determinations for items or services that may not be covered by Medicare. The new form includes several changes, including updates to the questions and instructions, and a redesigned worksheet. In this blog post, we will discuss the changes made to Form Hea 5801 with respect to coverage determinations. We will also provide an overview of how to complete the form correctly. Lastly, we will highlight key dates related to RFDMC submissions.

QuestionAnswer
Form NameForm Hea 5801
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshea5801 lead prior notification login form

Form Preview Example

Do Not Write In This Space

Postmark

Date received

Notiication number

Ohio Department of Health • Lead Poisoning Prevention Program

Prior Notiication of Lead Abatement Projects

Carefully read all the instructions and questions prior to completing the notiication form

1.Each lead abatement contractor shall notify the department of health at least 10 calendar days prior to the commencement of a project as required by Chapter 3742 of the Ohio Revised Code and Chapter 3701-32 of the Ohio Administrative Code. If the on-line prior notiication system is utilized the project notiication period is reduced to no less than three days.

2.Three day notiications utilizing the on-line system shall be submitted via access from the Ohio Department of Health webpage www.odh.ohio.gov. Ten day written notiications shall be legibly completed and sent to the Ohio Department of Health, Division of Quality Assurance, Attn: Lead Poisoning Prevention Program, 3rd loor, 246 North High Street, Columbus, Ohio 43215. You may also e-mail the original notiication to lead@odh.ohio.gov.

3.Please complete all sections of the notiication. The notiication will be returned if any information is lacking. The appropriate waiting period will commence when all information requested is supplied.

4. Type of notiication: c Original

cCancellation

c Revision # ____________________ Revised section number(s) _______ ________ ________

Complete the following information. Please be accurate and speciic when giving locations, names and dates.

5. Building owner name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

City

 

State

 

 

ZIP

 

 

 

 

 

 

 

Contact person

 

 

 

Telephone #

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Licensed Lead Abatement Contractor

 

 

 

 

 

 

 

 

 

 

 

 

License #

Expiration date

 

E-mail address

 

 

 

 

 

Employer

 

 

Telephone #

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

Employer street address

 

City

State

 

 

ZIP

 

 

 

 

 

 

Name of Risk Assessor/Inspector who performed testing, if applicable

 

License #

 

 

 

 

 

 

 

 

 

 

 

Project Information

7. Building type (check one)

 

 

 

County

 

 

 

Single family residential

c Multi-family residential

cChild Care Facility

c School

 

 

c

 

 

 

 

 

 

 

 

 

 

Address

 

 

City

State

ZIP

 

 

 

 

 

 

 

 

Site location (Include brief directions)

Project Description

8. Types of abatement

 

 

 

 

 

 

 

 

c Exterior work

c Component replacement

c Enclosure

c Encapsulation

c Dust abatement

 

c

Interior work

 

c Paint removal

c Soil

c Other (specify) ________________________________________________________________________________________

 

 

 

 

 

 

 

 

Abatement dates

9. Start date

 

 

 

 

Completion date

 

 

 

 

 

 

 

 

 

Hours of operation

 

 

 

 

 

 

 

c _________________ am to_________________ pm

c _________________ pm to_________________ am

 

 

 

 

 

 

 

 

 

Days of operation

 

 

 

 

 

 

 

c Monday

c Tuesday

c Wednesday

c Thursday

c Friday

c Saturday

c Sunday

Comments

10. Signature of person iling this notiication

Date

HEA 5801 (Rev. 06/11)

How to Edit Form Hea 5801 Online for Free

Whenever you would like to fill out Form Hea 5801, you won't need to download any software - simply give a try to our online PDF editor. FormsPal expert team is always endeavoring to enhance the editor and insure that it is even better for users with its many functions. Enjoy an ever-improving experience now! Here's what you would have to do to begin:

Step 1: Click the orange "Get Form" button above. It is going to open our editor so you can begin completing your form.

Step 2: After you start the tool, you'll notice the form prepared to be completed. In addition to filling in different blanks, you may also do several other things with the form, particularly adding your own text, changing the initial textual content, adding illustrations or photos, placing your signature to the document, and much more.

This PDF will need particular details to be filled out, therefore make sure to take some time to provide what's requested:

1. Start completing your Form Hea 5801 with a selection of essential blanks. Get all the necessary information and ensure nothing is omitted!

Tips on how to prepare Form Hea 5801 part 1

2. After this array of fields is completed, you're ready insert the essential details in Employer, Employer street address, City, Name of Risk AssessorInspector who, Project Information, Building type check one c Single, Address, City, Site location Include brief, Project Description, Telephone, State, License, County, and State so you can move forward further.

Ways to complete Form Hea 5801 step 2

3. Completing Days of operation c Monday c, Comments, Signature of person iling this, Date, and HEA Rev is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part # 3 for completing Form Hea 5801

Those who work with this form generally make some errors when completing Days of operation c Monday c in this area. You need to go over everything you enter here.

Step 3: Make certain your details are right and then click "Done" to proceed further. Acquire your Form Hea 5801 once you sign up for a free trial. Conveniently get access to the form inside your FormsPal account, along with any edits and changes being all kept! With FormsPal, you're able to complete documents without stressing about personal data breaches or entries being distributed. Our protected platform ensures that your private details are stored safe.

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