Get Cgs Provider-based Attestation Statement
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How to fill out the CGS Provider-Based Attestation Statement online
The CGS Provider-Based Attestation Statement is an essential document for facilities seeking provider-based status for billing and payment purposes as designated by the Centers for Medicare & Medicaid Services. This guide provides you with clear, step-by-step instructions to fill out the form online, ensuring compliance with applicable requirements.
Follow the steps to effectively complete the attestation statement.
- Press the ‘Get Form’ button to access the document and open it for online completion.
- Begin by filling out the main provider’s Medicare provider number and name. Ensure accuracy as this information is crucial for identification.
- Complete the main provider’s address, which must be exact, including building or suite number.
- Enter the application contact’s name, phone number, and email address. This information helps facilitate communication regarding the attestation.
- Provide the facility or organization’s name and its exact physical address, including any necessary details.
- If applicable, include the facility’s Medicare provider number and specify the exact distance from the main provider in yards or miles.
- Indicate the type of facility by checking the appropriate box, choosing between remote location, satellite facility, or hospital outpatient department.
- Confirm if the facility is part of a multi-campus hospital and if it is a Federally Qualified Health Center (FQHC). If it is an FQHC, make note of the relevant criteria.
- On the following sections, select whether the facility is ‘on campus’ or ‘off campus,’ and include the necessary compliance attestations by checking the appropriate boxes.
- Complete each attestation requirement, ensuring to read and understand the attached regulations referenced in the form.
- Before submitting, review the certification statement. Ensure all information is accurate and provides original ink signature if required.
- Once completed, save your changes, then download, print, or share the form as needed for submission to CGS.
Complete your CGS Provider-Based Attestation Statement online today to ensure the submission process is smooth and efficient.
An attestation clause is a section in a document where the signer confirms the authenticity of the information. For example, it may state, 'The undersigned attests that the information provided herein is accurate and complete as of the date signed.' Consider integrating the CGS Provider-Based Attestation Statement to ensure your documents include such clauses effectively.
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