Get Cms-671 2018-2025

The CMS-671 form is an important document for long-term care facilities applying for Medicare and Medicaid. This guide will help you navigate each section of the form with clear, step-by-step instructions to ensure accurate completion.

Follow the steps to successfully complete the CMS-671 online.

1. Press the ‘Get Form’ button to access the CMS-671 and open the form in the editor.
2. In the 'Name of Facility' field, enter the official business name of your facility, including any relevant components or units.
3. For 'Provider Number', leave this blank for initial certifications. If this is a recertification, provide the facility’s assigned six-digit provider code.
4. Fill in the 'Street Address' with the physical location of your facility, avoiding mailing addresses if they differ.
5. Enter the 'City' name relevant to the facility, including the nearest post office for rural addresses.
6. Input 'County' name, ensuring proper terms for your region, such as parish for Louisiana.
7. Provide the 'State' where the facility is located. For U.S. territories, this can substitute for state names.
8. Complete the 'Zip Code', using the standard or ‘Zip-plus-four’ code if available.
9. Include the 'Telephone Number', making sure to add the area code.
10. Leave 'State/County Code' and 'State/Region Code' blank, as these will be filled out by the State Survey Office.
11. In Block F9, indicate facility type with codes: 01 for Skilled Nursing Facility, 02 for Nursing Facility, and 03 for both.
12. For Block F10, specify whether the facility is hospital-based by selecting 'yes' or 'no'.
13. If you answered 'yes' to Block F10, enter the Hospital Provider Number in Block F11.
14. In Block F12, choose the type of ownership governing your facility (e.g., For-Profit or Non-Profit) and provide the appropriate code.
15. In Block F13, specify if the facility is owned or leased by a Multi-Facility Organization.
16. If applicable, provide the name of the Multi-Facility Organization in Block F14.
17. For Blocks F15 to F23, enter the number of beds allocated for each Dedicated Special Care Unit as applicable.
18. In Block F24, check 'yes' if there is an organized residents’ group; otherwise, check 'no'.
19. In Block F25, denote whether there is an organized group of family members of residents.
20. For Block F26, indicate if experimental research is conducted at the facility.
21. In Block F27, verify whether the facility is part of a Continuing Care Retirement Community.
22. For Blocks F28 to F31, if a staffing waiver exists, write in the dates of approval and number of hours waived.
23. In Block F32, confirm if there is an approved Nurse Aide Training and Competency Evaluation Program.
24. Finally, provide the 'Name of Person Completing Form', along with the time, signature, and date before finalizing the form.

Begin your document processing and fill out the CMS-671 online today!