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Get Cms-417 2015-2025
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How to fill out the CMS-417 online
The CMS-417 form is essential for hospice providers seeking Medicare certification. This guide will help you navigate the process of completing the form online, ensuring you provide the necessary information accurately.
Follow the steps to complete the CMS-417 online.
- Click the ‘Get Form’ button to access the CMS-417 document and open it in your preferred online editor.
- In the 'Identifying Information' section, enter the name of your hospice and its complete street address.
- Indicate your request to establish eligibility in the Medicare program by selecting the appropriate block.
- Enter the six-digit Medicare certification number for your facility, leaving the field blank if this is your initial request.
- Complete the 'Related certification number' field if applicable, entering the six-digit Medicare certification number of any affiliated providers.
- In the 'Type of Control' section, select the appropriate option to specify the nature of your hospice (e.g., proprietary, government).
- For the 'Services Provided' section, place a ‘1’, ‘2’, or ‘3’ in the respective blocks depending on how services are provided, whether directly by staff or through arrangements.
- Fill out the 'Number of Employees/Volunteers' section, providing total counts for full-time equivalents across various professional categories.
- In the 'Name of Authorized Representative' section, type the name and title of the person completing the form, then sign and date the document accordingly.
- Review all entries for accuracy and completeness before proceeding to save changes. You may also choose to download, print, or share the completed form as needed.
Complete your CMS-417 form online today to ensure your hospice can access Medicare benefits.
When filling out a Medicare termination form, such as the CMS 1763, it’s important to provide accurate personal information and reasons for termination. Carefully follow the instructions included with the form to ensure you don’t miss any required sections. Taking your time while completing this form helps prevent delays in processing your request. USLegalForms is available to help you understand each step involved.
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