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Get CMS-473B 2019-2024

ROOM NUMBERS IN THE HOSPITAL NUMBER OF BEDS IN THE HOSPITAL SURVEY DATE REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD FACILITY NAME AND ADDRESS (City, State, Zip Code) / / to / / MM DD YYYY MM DD YYYY VERIFIED BY ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM MEDICARE’S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM TAG REGULATION GUIDANCE Verification of hospital attestations may be done by CMS surveyors or MACs as applicable. THE HOSPI.

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