Get Cms-3427 2013-2025

The CMS-3427 form serves as the end stage renal disease application and survey and certification report, essential for Medicare program compliance. This guide will walk you through the process of completing the form online, ensuring that you meet all necessary requirements.

Follow the steps to successfully complete the CMS-3427 form.

1. Press the ‘Get Form’ button to access the CMS-3427 document and open it in your preferred online editor.
2. Begin with item 1 and select the type of application by checking all applicable boxes (e.g., initial, relocation, or change of ownership). If you select 'Other,' make sure to specify in the remarks section.
3. Proceed to items 2 through 10, where you will provide identifying information about your facility, including its name, CCN, address, and contact details.
4. For item 11 through 14, fill in the administrator’s email, telephone, and facsimile numbers. Confirm the status of Medicare enrollment by checking 'Yes' or 'No' in item 14.
5. In item 15, input the facility administrator's name and address details.
6. Complete item 16 by selecting the ownership status of your facility and providing the necessary telephone information.
7. Items 17 and 18 require you to indicate if the facility is hospital-based or located in a skilled nursing facility. Check 'Yes' or 'No' accordingly.
8. Fill items 19-25 by providing details about multi-facility ownership and the services your facility currently offers and what new services you are requesting.
9. Document the number of current dialysis patients in item 23, along with the number of approved in-center dialysis stations in item 24.
10. Complete all staffing-related information in item 30, ensuring to list staffing equivalents correctly.
11. Fill in any remarks that pertain to the earlier items in section 33. Make sure to clarify any information necessary.
12. Affix your signature as the administrator or medical director in the specified section, confirming the truthfulness of the information provided.
13. Review your completed form for accuracy and ensure all required documentation is attached. After final checks, proceed to save changes, download, print, or share the form as needed.

Complete and submit your CMS-3427 online today to ensure compliance with the Medicare program.