DATA REPORT PROVIDER CCN: PERIOD : FROM: TO: FORM APPROVED OMB NO. 0938-0758 WORKSHEET S PARTS I & II PART I - COST REPORT STATUS 1 Provider use only Contractor use only: 1 2 3 4 5 6 7 8 9 10 11 12 Electronic filed cost report Manually submitted cost report Number of times cost report has been amended Medicare utilization Cost report status 1 As Submitted 2 Reserved 3 Reserved 4 Reserved 5 Amended Date received Contractor number First cost report for this provider CCN.

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How to fill out the HHS Form CMS-1984-14 online

Filling out the HHS Form CMS-1984-14 is an essential task for hospice providers seeking to document their cost reports accurately. This guide will help you navigate the online form with step-by-step instructions to ensure all sections and fields are completed correctly.

Follow the steps to complete the HHS Form CMS-1984-14 effectively.

  1. Click the ‘Get Form’ button to access the CMS-1984-14 document and open it in your online form editor.
  2. Begin by entering your Provider CCN and the reporting period details in the designated fields. Ensure accuracy as this information is critical for processing your report.
  3. In Part I, provide the cost report status by selecting the appropriate radio button. Indicate if this is your first or last cost report for this Provider CCN where required.
  4. Proceed to fill in the certification section. An authorized officer or administrator must certify that the information provided is accurate. Ensure to include their printed name, title, and date of certification.
  5. Fill out Part II and gather statistical data by accurately entering all relevant figures pertaining to services provided during the specified period.
  6. Continue to complete Worksheets A, B, and other necessary sections in accordance with the instructions provided within the form for various cost centers.
  7. Once all sections are deemed complete, review your entries for any discrepancies or missing information. Utilize the provided instruction guidance if needed.
  8. Finally, save your changes. You can download, print, or share the form as required, ensuring to keep copies for your records.

Get started by filling out your HHS Form CMS-1984-14 online today!

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