Laboratory Personnel Cms 209 Form – Fill Out and Use This PDF

The Laboratory Personnel Cms 209 Form is an essential part of the laboratory process. It must be completed correctly and on time in order to properly document the conditions, employees, equipment, and other requirements in a laboratory setting. This form is mandatory for all personnel in any kind of lab environment as it allows for homogeneity between laboratories and simplifies regulatory compliance. Each of the sections identified by the CMS covers requirements for Quality Assurance, Shipping and Receiving Processes, Human Resources related to Employee Training, Scheduling Procedures, Master Test Plans (MTP) or Regulatory Forms such as Hazard Analysis Critical Control Point (HACCP), Caustic Motor Fluorescent Lamp exposure screenings, Dosimetry Monitoring Equipment calibration as well as how to handle field genetics Laboratory Tests Modules properly. The CMS forms ensures that all laboratory environments thrive under uniform requirements without discrepancies across different sites and personnel use high end quality assurance methods befitting of the industry’s standards.

Laboratory Personnel Cms 209 Form PDF Details

Are you in charge of the laboratory personnel at your facility? If so, it is important to be aware of CMS Form 209. This form — which is officially known as the "Request for Anticipated Payment by Medicare Carriers" — is used when applying for anticipated payments from Medicare carriers and other third-party payers. It helps ensure that laboratory personnel receive timely compensation from insurance providers and that all necessary documentation has been provided accurately. In this blog post, we’ll discuss what a CMS Form 209 covers and how to fill them out quickly and correctly—helping simplify operations for any lab manager or administrator responsible for billing in a medical setting.

Question	Answer
Form Name	Laboratory Personnel Cms 209 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	fillable 209, 209 laboratory, cms form 209, cms 209 fillable

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES	Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES	OMB No. 0938-0151

LABORATORY PERSONNEL REPORT (CLIA)

(For moderate and high complexity testing)

1. LABORATORY NAME

2. CLIA IDENTIFICATION NUMBER

3. LABORATORY ADDRESS (NUMBER AND STREET)

CITY

STATE

ZIP CODE

4. INSTRUCTIONS:

POSITIONS:

5. TELEPHONE (INCLUDE AREA CODE)

a. List below all technical personnel, by name, who are employed by the

D-Director

laboratory. Check (4) the appropriate column for each position held. For TC

CC - Clinical Consultant

and TS follow instructions on reverse. For a moderate complexity laboratory,

TC - Technical Consultant

TS - Technical Supervisor

FOR OFFICIAL USE ONLY

list the positions of D, CC, TC and TP. For a high complexity laboratory, list the

GS - General Supervisor

(NOT TO BE COMPLETED BY LABORATORY)

positions of D, CC, TS, GS and TP. For cytology, list D, CC, TS, CT/GS and CT.

TP- Testing Personnel

QUALIFIES ACCORDING TO SUBPART M

b. Indicate highest level of testing for which personnel are qualified: Use (M) for

CT/GS - Cytology General Supervisor

moderate and (H) for high complexity.

CT - Cytotechnologist

DATE OF SURVEY ___________________________

EMPLOYEE NAMES

POSITION HELD

LAST NAME

FIRST NAME

D CC

CT/GS

oCheck (4) here if additional space is needed to list all technical personnel. Copy this page and attach continuation sheet(s) to the original form.

READ THE FOLLOWING CAREFULLY BEFORE SIGNING

Statement or Entities Generally: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both. (U.S. Code, Title 18, Sec. 1001)

CERTIFICATION: I CERTIFY THAT ALL OF THE INDIVIDUALS LISTED ABOVE QUALIFY, TO FUNCTION IN THE POSITION INDICATED, ACCORDING TO THE PERSONNEL REGULATIONS OF 42 CFR PART 493 SUBPART M.

6. SIGNATURE OF LABORATORY DIRECTOR

7. DATE

FORM CMS-209 (09/2018)

IF CONTINUATION SHEET PAGE ___ OF ___

INSTRUCTIONS FORM CMS-209

This form will be completed by the laboratory. It will be used by the surveyor to review the qualifications of technical personnel in the laboratory.

INSTRUCTIONS

1.Only one person may be listed as the laboratory director (D).

2.For a moderate complexity laboratory, list the positions of D, CC, TC and TP. For a high complexity laboratory, list the positions of D, CC, TS, GS and TP. For cytology, list D, CC, TS, CT/GS and CT.

3.Do not list individuals that only perform waived testing, no testing, and administrative functions.

4.Use a separate line for individuals performing more than one CLIA position.

5.For 4(a) TC/TS:

When listing those individuals holding technical consultant/technical supervisor (TC/TS) positions, use the following grid to indicate the specialty(ies)/subspecialty(ies) in which they presently function. Record the number corresponding to the specialty/subspecialty in the appropriate column (TC/TS). When an individual functions as a TC/TS in more than one specialty/subspecialty, use a line for each specialty/subspecialty.

GRID:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES	10. Clinical Cytogenetics
1. Bacteriology	10. Clinical Cytogenetics

	2.	LABORATORY PERSONNEL REPORT (CLIA)
		Mycobacteriology		11.	Histocompatibility
	3.	Mycology	(For moderate and high complexity testing)
				12.	Radiobioassay
1. LABORATORY NAME		Parasitology		13.	Histopathology
	4.
	5.	Virology		14.	Oral Pathology
3. LABORATORY ADDRESS (NUMBER AND STREET)					CITY
	6.	Diagnostic Immunology		15.	Cytology
4. INSTRUCTIONS:	7. Chemistry			16.	PDermatopathologyOSITIONS:
a. List below all technical personnel, by name, who are employed by the				17.	D-Director
	8.	Hematology			CCOphthalmic- Clinical ConsultantPathology
laboratory. Check (4) the appropriate column for each position held. For TC					TC - Technical Consultant
and TS follow instructions on reverse. For moderate complexity laboratory,
	9.	Immunohematology			TS - Technical Supervisor
list the positions of D, CC, TC and TP. For a high complexity laboratory, list the					GS - General Supervisor
positions of D, CC, TS, GS and TP. For cytology, list D, CC, TS, CT/GS and CT.
					TP- Testing Personnel
b. Indicate highest level of testing for which personnel are qualified: Use (M) for					CT/GS - Cytology General Supervisor
EXAMPLEmoderate and (H) for high complexity.					CT - Cytotechnologist

Form Approved

OMB No. 0938-0151

2. CLIA IDENTIFICATION NUMBER

STATE

ZIP CODE

5.TELEPHONE (INCLUDE AREA CODE)

FOR OFFICIAL USE ONLY

(NOT TO BE COMPLETED BY LABORATORY) QUALIFIES ACCORDING TO SUBPART M

DATE OF SURVEY ___________________________

EMPLOYEE NAMES

POSITION HELD

LAST NAME

FIRST NAME

D CC TC TS

CT/GS

Smith

John

FOR OFFICIAL USE ONLY

Indicate the applicable regulatory citation under which the following individuals are qualified: Each laboratory director, technical consultant, technical supervisor, clinical consultant, general supervisor, cytology supervisor, and those testing personnel and cytotechnologist sampled during the survey process.

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 0938-0151. Expiration Date: 9/30/2021. The time required to complete this information collection is estimated to average 30 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 comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact LabExcellence@cms.hhs.gov.

FORM CMS-209 (09/2018)

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Part no. 1 of filling out laboratory personnel

2. Right after the first selection of fields is filled out, proceed to enter the relevant details in these - o Check here if additional space, sheets to the original form, READ THE FOLLOWING CAREFULLY, and Statement or Entities Generally.

sheets to the original form, Statement or Entities Generally, and READ THE FOLLOWING CAREFULLY in laboratory personnel

3. The next step is normally straightforward - fill out all the form fields in SIGNATURE OF LABORATORY DIRECTOR, DATE, FORM CMS, and IF CONTINUATION SHEET PAGE OF to complete this part.

laboratory personnel writing process shown (step 3)

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Laboratory Personnel Cms 209 Form – Fill Out and Use This PDF

Laboratory Personnel Cms 209 Form PDF Details

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