Different from above) E-Mail Address Zip Code Manufacturing Plant(s) Name and Street Address (if different from above) Name/Title of Person Completing Certification 2. Website Address The undersigned certifies under oath that as of the date of this Certification, the above - named applicant is (initial one): a Participating Manufacturer ( PM ). (If applicant is a PM, it may skip the remainder of Part I and go directly to Part II.) a Nonparticipating Manufacturer ( NPM.
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How to fill out the Form AS 2746 online
Filling out the Form AS 2746 is essential for tobacco product manufacturers seeking to list their products in the Puerto Rico Directory. This guide will provide clear, step-by-step instructions to assist users in completing the form accurately and efficiently.
Follow the steps to complete the Form AS 2746 online.
- Press the ‘Get Form’ button to obtain the form and open it in the editor.
- Complete Part I by providing general business and ownership information. Include the applicant's name, Employer Identification Number, address, and contact details. Specify if the applicant is a Participating Manufacturer or Nonparticipating Manufacturer by marking the appropriate box.
- If applicable, list the manufacturing plant(s) name and address, along with the contact person's name and title. Ensure to provide a website address if available.
- In Part II, identify the brand families. Fill out the Brand Families Unit Sales Schedule and provide necessary details about trademark holders.
- Proceed to Part III and indicate whether various statements regarding the applicant's business activities are true by marking 'Yes' or 'No'.
- If you are a Nonparticipating Manufacturer, complete Part IV, detailing your agent for service of process and confirming the establishment of a Qualified Escrow Fund.
- In Part V, report on any returns or destructions of brand families during the previous year, providing necessary details.
- Carefully read the declaration, acknowledgment, and signature section. Ensure it is signed by an authorized individual and all fields are completed accurately.
- Finally, save changes, download a copy, print, or share the completed form as needed.
Start filling out the Form AS 2746 online today to ensure compliance and secure your listing.
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Complete the ESRD Death Notification, CMS-2746, within 2 weeks of the date of death. If the patient was a dialysis patient, the dialysis facility last responsible for the patient's maintenance dialysis (or home dialysis) must complete this form.
What is a 2,746 cause of death?
A CMS-2746 form (End Stage Renal Disease Death Notification) is completed by providers to notify Medicare of the death of an End Stage Renal Disease (ESRD) patient, including the date and cause of death. The Federal Government requires the reporting of all deaths of ESRD patients.
What is the end stage renal disease prospective payment system?
The ESRD PPS provides a bundled, per-treatment payment to ESRD facilities that includes all renal dialysis services furnished for outpatient maintenance dialysis, including drugs and biological products (with the exception of oral-only ESRD drugs until 2025).
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