Get Cms-417 1984

The CMS-417 form, known as the Hospice Request for Certification in the Medicare Program, is essential for obtaining or retaining Medicare benefits. This guide will walk you through each section of the form, providing clear and supportive instructions to ensure you fill it out accurately.

Follow the steps to complete the CMS-417 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Item I, provide the name of the Hospice in the designated field. Ensure that this is filled out correctly as it identifies your organization.
3. Fill in the Street Address, City, County, and State fields. Ensure all information is up-to-date for accurate processing.
4. Under the Request to Establish Eligibility In section, mark '1' for Medicare benefits, as these are the current benefits available.
5. Enter the Medicare provider number in the designated field if available, or leave it blank for initial certification requests.
6. Skip the State/County and State/Region Codes; these will be completed by the Centers for Medicare & Medicaid Services.
7. If applicable, fill in the Related Provider Number, which is the Medicare Provider Number of any affiliated facility.
8. In Item II, select the type of hospice by checking the appropriate box that corresponds to your facility type.
9. Under Item III, indicate the type of control by checking the box that reflects your organization’s structure, such as Non-Profit or Proprietary.
10. In Item IV, for each service provided, indicate whether it is by staff or under an arrangement by placing '1' or '2' in the appropriate blocks.
11. Complete the Number of Employees/Volunteers Full-time Equivalent section by entering the total number of employees and volunteers in their respective fields.
12. Finally, enter the name and title of the authorized representative, ensuring their signature and date are included before submission.
13. Once you have filled out all sections, save your changes, and you can download, print, or share the completed form as needed.

Complete your CMS-417 form online to streamline your certification process.