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Get CMS-437A 2019-2024

437A as well as a signed attestation statement attesting that the rehab unit s patients it intends to serve meets the requirements outlined in 412. 29 b 2. The IRF must submit an attestation statement in addition to the Form CMS 437A of their initial application packet. Until the SA receives both the attestation statement and the Form CMS 437A the new unit cannot be recommended for approval. A3512 1 New IRFs. 1 a 1 a rehabilitation unit must meet the following requirements in addition to the all criteria under Subpart B of Part 412 of the regulations Form CMS-437A 06/12 In the case of 412. 29 b 2 the MAC notifies the RO. A3511 c In the case of new IRFs as defined in paragraph c 1 of this section or new IRF beds as defined in paragraph e 2 of this section the IRF must provide a written certification that the inpatient population it intends to serve meets the written certification will apply until the end of the IRF s first full 12-month cost reporting period or in the case of new IRF beds until the end of the cost reporting period during which the new beds are added to the IRF. exclusion. approval for the unit under the appropriate State licensure laws. 437A as well as a signed attestation statement attesting that the rehab unit s patients it intends to serve meets the requirements outlined in 412. FORM APPROVED OMB NO. 0938-0986 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES REHABILITATION UNIT CRITERIA WORK SHEET RELATED MEDICARE PROVIDER NUMBER ROOM NUMBERS IN THE UNIT NUMBER OF BEDS IN THE UNIT SURVEY DATE REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD FACILITY NAME AND ADDRESS City State Zip Code / to MM DD YYYY VERIFIED BY ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM MEDICARE S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM OR FROM THE PAYMENT SYSTEM USED TO PAY CRITICAL ACCESS HOSPITALS* REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM Verification of hospital attestations may be done by CMS surveyors or MACs as applicable. TAG The hospital representative is expected to answer all questions accurately. The representative should verify the answers with the director of rehabilitation physician medical records office or any applicable department to ensure correct responses to this form* A yes response means the hospital is in compliance with the applicable regulation* 412. 25 Excluded hospital units Common requirements. a Basis for exclusion* In order to be excluded from the prospective payment systems specified in 412. 25 and 412. 29 as related to IRF units the term hospital includes Critical Access Hospitals. YES NO N/A A3500 1 Be part of an institution that has in effect an agreement under Part 489 to participate as a hospital and is not excluded in its entirety from the prospective payment systems and has enough beds that are not excluded to permit the provision of adequate cost. The surveyor will verify through the regional office RO that the hospital has an agreement to partici ate in the Medicare program and the p hospital is not already excluded in its entirety from IPPS such as a rehabilitation hospital* In other words the unit seeking exclusions cannot comprise the entire hospital Representative to ensure the hospital has a Medicare provider agreement.

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