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On on the official letterhead of the main provider if you elect to use this or any other format. Attestations should be submitted to your fiscal intermediary (FI) or Medicare Administrative Contractor (MAC) with a copy to your CMS Regional Office. Please note that provider-based determinations under 42 CFR 413.65 in relation to hospitals are not made for the following facilities: ambulatory surgical centers (ASCs), comprehensive outpatient rehabilitation facilities (CORFs), home health agencies .

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