Get Exhibit 286 Fillable Form

The Exhibit 286 Fillable Form is an essential document used to collect information about hospitals and critical access hospitals participating in Medicare. This guide will provide you with a step-by-step approach to effectively complete the form online.

Follow the steps to accurately fill out the Exhibit 286 Fillable Form online.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin with the basic information section. Fill in the CMS Certification Number (CCN), Date of Worksheet Update, and the Medicaid Provider Number. Ensure that you enter the information accurately.
3. Next, enter the National Provider Identification Number(s) (NPI), Fiscal Year Ending Date, and the full name and address of the facility, including city, state, and zip code.
4. Provide the telephone number and fax number of the facility, followed by the CEO telephone number, email address, and website address if applicable.
5. In the accreditation section, select the appropriate accreditation status for the facility. Ensure that you fill in the Effective Date of Accreditation and Renewal Date of Accreditation as required.
6. Complete the multiple accreditation status if applicable, and provide state and county codes along with the type of program participation.
7. Include all necessary details regarding CLIA ID Numbers and type of Medicare hospital. Choose the correct category that applies to your facility.
8. Follow with information about the ownership type, average daily census, number of staffed beds, and chain/system involvement.
9. Fill out the salaried employee information accurately for each specified category and select applicable Medicare payment-related categories.
10. Indicate all services provided by the facility and document the sprinkler status regarding the main campus.
11. Finally, include the total number of provider-based off-site locations and the number of related or affiliated providers or suppliers.
12. Review all of the filled sections for accuracy. At the end, you can save your changes, download, print, or share the completed form.

Complete your Exhibit 286 Fillable Form online today for a streamlined submission.