Get Cgs Provider-based Attestation

The CGS Provider-Based Attestation is a crucial document used to confirm a facility's compliance with the requirements set by the Centers for Medicare & Medicaid Services. This guide provides clear and supportive instructions for filling out the attestation online, ensuring that users understand each part of the form.

Follow the steps to complete your attestation form accurately.

1. Press the ‘Get Form’ button to access the attestation form. This will open the document in an editable format for you to complete.
2. Begin by entering the main provider's Medicare provider number in the designated field at the top of the form. Make sure this information is accurate to ensure proper processing.
3. Input the main provider's name and address. It's important to provide the full and correct address, including any relevant building or suite numbers.
4. Fill in the application contact's name, phone number, and email address. This should be the person responsible for any communications related to this attestation.
5. In the next section, list the facility or organization’s name and its exact physical address, incorporating all details such as building and suite numbers.
6. If applicable, include the Medicare provider number for the facility/organization. Following that, indicate the exact distance in yards or miles between the main provider and the facility.
7. Select the appropriate classification for the facility from the options provided: remote location of a hospital, satellite facility, or hospital outpatient department.
8. Indicate whether the facility is part of a multi-campus hospital and specify if it is a Federally Qualified Health Center (FQHC).
9. Record the date when the facility became provider-based with the main provider. This section is important for establishing the timeline of your provider-based status.
10. Proceed to the section describing types of services provided. Mark whether the facility is on-campus or off-campus based on the distance from the main provider.
11. Initial the appropriate certification selection indicating compliance with the relevant provider-based requirements outlined in the document.
12. Complete the checklist confirming compliance with each requirement stated for being provider-based.
13. Finally, review all entries for accuracy before you save your changes, download a copy, print the form, or share it as needed.

Complete your CGS Provider-Based Attestation online today to ensure your facility meets the necessary requirements for provider-based designation.