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Get CMS-671 2018

This form “the facility” equals certified beds (i.e., Medicare and/or Medicaid certified beds). Standard Survey: LEAVE BLANK – Survey team will complete. Extended Survey: LEAVE BLANK – Survey team will complete. INSTRUCTIONS AND DEFINITIONS Name of Facility: Use the official name of the facility for business and mailing purposes. This includes components or units of a larger institution. Provider Number: Leave blank on initial certifications. On all recertifications, insert the facility.

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