Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In Section I, enter the healthcare provider information. Fill in your CMS Medicare provider number, the name and address of your facility, and the administrator's details including the name, telephone, and fax numbers.
3. Specify the type of facility and provide the corporate affiliation if applicable. Indicate the number of employees and select the reason for application by circling either initial Medicare certification or change of ownership.
4. In Section II, gather and upload required documents. Start with the assurance of compliance form (HHS 690), and ensure it is completed, signed, and dated.
5. Prepare the nondiscrimination policy that aligns with Title VI of the Civil Rights Act, and describe how you disseminate this policy among patients and staff.
6. Provide facility admissions policies that outline eligibility requirements for services and any descriptions of policies that may restrict admissions based on age.
7. For facilities with 15 or more employees, include a copy of your procedures on handling disability discrimination grievances along with contact information for your Section 504 coordinator.
8. Detail your procedures for effective communication with individuals who are limited English proficient, including how to identify those needing assistance and available resources.
9. Outline methods for communication with individuals who are deaf or hard of hearing, including available auxiliary aids and how to inform users about these services.
10. In Section III, certify that all information provided is true and complete. Enter the name and title of the authorized official, obtain their signature, and date the form.
11. Once all sections are complete, save your changes. You can then download, print, or share the filled form as necessary.

Start filling out your form online today to ensure a smooth submission process.