Get Cms Critical Access Hospital Reconsideration Application 2019-2025

This guide provides a clear and supportive approach to completing the CMS Critical Access Hospital Reconsideration Application online. Follow these instructions to ensure your application is filled out accurately and submitted on time.

Follow the steps to complete your application efficiently.

1. Click ‘Get Form’ button to acquire the form and open it for filling.
2. Begin with Section 1: Hospital Information. Enter the legal hospital name, CMS Certification Number, and National Provider Identifier. Ensure that all required fields marked with an asterisk (*) are completely filled out, including the hospital address and contact information.
3. Proceed to Section 2: Payment Adjustment Reconsideration. Indicate whether the Critical Access Hospital has previously demonstrated meaningful use by selecting 'Yes' or 'No'. Then, specify the type of payment adjustment reconsideration applicable by selecting at least one option listed.
4. Complete Section 3: Certification Statement Confirmation. Ensure that the person submitting the application certifies the information is true and accurate by including their confirmation and the date. This is legally significant, as it asserts the accuracy of the submitted information.
5. Once all sections are completed, save your changes. You must download the application to your device before submission. Ensure the file format is proper and accessible.
6. To submit the application, attach the completed document to an email and send it to qnetsupport@hcqis.org, or if electronic submission is unfeasible, fax it to 845-559-6370. Retain a copy of your submitted application for your records.

Act now to complete and submit your CMS Critical Access Hospital Reconsideration Application online.