CMS-377 Ambulatory Surgical Center Request for Certification in

FORM APPROVED
OMB NO 0938-0266

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(Please see statement on reverse and read the following instructions before completing this form)
Submission of this form will initiate the process of obtaining a decision as to
whether the Conditions of Coverage are met. Assistance in completing the
form is available from the State agency.

participating as a hospital. The number in this block for each related
provider will be the provider number of the highest level of care.
NOTE: If an ASC is operated by a hospital, has a Distinct Part SNF, ICF
and ICF/MR, the related provided number field on the application for each
provider (including the hospital) will have the hospital provider number.

Answer all questions as of the currrent 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.

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

Detailed instructions are given for questions other than those considered
self-explanatory.

Item III - If a service is provided directly by the facility, place a ‘1’ in the
appropriate block. If a service is provided through an outside source (i.e., by
contract or referral), place a ‘2’ in the appropriate block.

Medicare Supplier Number - Insert the facility’s six-digit supplier number.
Leave blank on initial requests for certification.
Related Provider Number - Complete this block when a facility is
participating under more than one provider number, such as a facility also

Item IV - ‘X’ the appropriate blocks representing categories of surgery
offered by the ASC. Under “Other,” include only broad categories (i.e., not
subspecialties).

Medicare Supplier Number Related Provider Number

State Region Code

AS2

AS1

I

IDENTIFYING
INFORMATION

State/County Code

Fiscal Year Ending Date
AS4

AS3

Name of Facility

Street Address

City, County, and State

Zip Code

AS5

Telephone No. (Include Area Code)
AS6

II
III

IV

TYPE OF CONTROL
(x one box)

ANCILLARY
SERVICES
(Place ‘1’ or ‘2’
in blocks) AS8

SURGICAL
SPECIALTIES
(X appropriate
blocks)
AS9

V

1. ■ Proprietary

3. ■ Government

2. ■ Non-Profit

AS7

1. ■ Laboratory
1. ■
2. ■
3. ■
4. ■
5. ■

Cardiovascular
Foot
General
Neurological
Obstetrics/Gynecology

3. ■ EKG

2. ■ Radiology
6. ■
7. ■
8. ■
9. ■
10. ■

11. ■ Thoracic
12. ■ Urology
13. ■ Other (Specify) ________________
_____________________________

Ophthalmology
Oral
Orthopedic
Otolaryngology
Plastic

FACILITY
1. Number of Operating Rooms _________________________
CHARACTERISTICS

4. ■ Pharmacy

2. Date Center Began Providing Services _________________________
AS10

AS11

WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT, MAY BE
PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY
DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OR 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.
Signature of Authorized Official (sign in ink)

Title

Date

AS12
Form CMS-377 (01/97) EF (10/2004)

According to the Paperwork Reduction 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 0938-0266. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, searching 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 estimates(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance
Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.