Form CMS-417 Hospice Request for Certification in the Medicare Progra

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB No.0938-0313

INSTRUCTIONS FOR COMPLETING HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM

STATEMENT CONCERNING INFORMATION COLLECTION REQUIREMENTS AND USES
This form is required to obtain or retain Medicare benefits. It serves two purposes. First, it provides basic information about the Hospice which is necessary for
the State to properly schedule a survey. Second, it provides a data-base necessary for responding to questions frequently asked by Congress, Federal agencies,
and interested members of the public.
Submission of this form will initiate the process of obtaining a decision as to whether
the Conditions are met.

Item IV – If a service is provided directly by the facility place a “1” the appropriate
block. If a service is provided through an outside source (i.e., by contract/arrangement),
place a “2” in the appropriate block.

Answer all questions as of the current date. Return the original and first two copies
to the State Agency; retain the last copy for your files. If a return envelope is not
provided, the name and address of the State Agency may be obtained from the
nearest Social Security Office.
Detailed instructions are given for questions other than those considered
self-explanatory.
Item I
•

Request to establish eligibility in - current Hospice Benefits are available only
through the Medicare program.

•

Medicare provider number - insert the facility's six digit Medicare Provider
Number. Leave blank on initial requests for certification.

•

State/County and State/Region Codes – Leave blank. The Centers for Medicare
& Medicaid Services Regional Office will complete.

•

Related provider number – If Hospice is affiliated with any other type Medicare
provider, insert the related facility's six digit Medicare Provider Number.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0313. The time required to complete this information collection is estimated to average 15 minutes per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland
21244-1850.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB No. 0938-0313

HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(Read Instructions and Information Collection Statement On Cover Sheet of Form Prior to Completion)
I. Identifying Information

Name of Hospice

Street Address

Request to Establish Eligibility In
1. ____ Medicare

City, County and State

Zip Code

PH1
Medicare/Provider Number
PH2
II. Type of Hospice
(Check One)

1.
2.
3.
4.
5.

■
■
■
■
■

State/Region

State/County

Related Provider
Number

Telephone Number
(include area code)
PH4

PH3

Hospital
Skilled Nursing Facility
Intermediate Care Facility
Home Health Agency
Freestanding Hospice

PH5

For Hospitals Only (Check One)
A. ■ JCAH Accredited
B. ■ AOA Accredited
C. ■ Both JCAH and AOA Accredited
D. ■ Non-Accredited

PH6
Fiscal Year Ending
Date

PH7
III. Type of Control
(Check One)

Non-Profit
1. ■ Church
2. ■ Private
3. ■ Other

Proprietary
4. ■ Individual
5. ■ Partnership
6. ■ Corporation
7. ■ Other

PH8
IV. Services Provided:
By staff, place a "1"
in the block(s)
If under arrangement,
place a "2" in the
block(s)

Core:
1. ■ Physician Services
5.
6.
7.
8.
9.
10.
11.
PH9

V. Number of Employees/
Volunteers Full-time
Equivalent (Top section of
professional category
reflects total number of
FTE (i.e., PH 11 through
PH 18))

■
■
■
■
■
■
■

Government
8. ■ State
9. ■ County
10. ■ City
11. ■ City-County

2. ■ Nursing Services

12. ■ Combination
Government and
Nonprofit
13. ■ Other

3. ■ Medical Social Services

Name and Address of Contractee
Physical Therapy
Occupational Therapy
Speech-Language Pathology
Home Health Aide
Homemaker
Medical Supplies
Short Term lnpatient Care

12. ■ Other(Specify)

PH1O
A. ______Acute
B. ______Respite

Employees

Licensed Practical Nurses/
PH11 Registered Professional
Licensed Vocational Nurses
Nurses
PH12
Volunteers
Employees
Volunteers
Employees
Volunteers

A.
Homemakers
Employees

A.
B.
A.
PH15 Home Health Aide
PH16 Counselors
Volunteers Employees
Volunteers
Employees

Physicians

4. ■ Counseling Services
Medicare Provider/Supplier
Number

B.

B.
Volunteers

Medical Social
Total Number
Workers
PH14
Employees
Volunteers
A.
PH17 Others
Employees

B.

PH19
PH18 Employees Volunteers
Volunteers

A.
B.
A.
B.
A.
B.
A.
B.
A.
B.
Whoever knowingly or willfully makes or causes to be made a false statement or representation on this form may be prosecuted under applicable Federal or State laws. In addition, knowingly
and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate, or where the entity already participates, a termination of its agreement
or contract with the State agency or the Secretary as appropriate.
Name of Authorized Representative and Title (Typed)

Signature

Date
PH20

Form CMS-417 (04/84)