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.
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 certification number:
Insert the facility’s six digit Medicare Certification 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 certification number:
If Hospice is affiliated with any other type Medicare provider, insert the related facility’s six digit Medicare Certification Number.

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.

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

City, County and State

1.

Medicare

PH1

Medicare/Certification Number

1.
2.
3.
4.
PH7 5.

III. Type of Control
(Check One)
PH8

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

Telephone Number
(include area code)

Proprietary:

Government:

1.
2.
3.

4.
5.
6.
7.

Individual
Partnership
Corporation
Other

8.
9.
10.
11.

2.

Nursing Services

5.
6.
7.
8.
9.
10.
11.
12.

Physical Therapy
Occupational Therapy
Speech-Language Pathology
Hospice Aide
Homemaker
Medical Supplies
Short Term lnpatient Care
Other(Specify)

PH9
Physicians
Employees
A.
Homemakers
Employees
A.

PH5

3.

State
County
City
City-County

12.
13.

Medical Social Services

Name and Address of Contractee

4.

PH6
Fiscal Year Ending Date

For Hospitals Only (Check One)
The Joint Commission Accredited
A.
B.
AOA Accredited
C.
Both The Joint Commission and AOA Accredited
D.
Non-Accredited

Non-Profit:
Church
Private
Other

Related Certification Number

PH4

PH3

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

Core:
1.
Physician Services

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)

State/Region

State/County
PH2

II. Type of Hospice
(Check One)

Zip Code

Combination Government
and Nonprofit
Other

Counseling Services

Medicare Certification/Supplier Number

PH1O
A. ______Acute
B. ______Respite

Registered Professional Nurses
PH11
PH12
Volunteers
Employees
Volunteers
B.
A.
B.
Hospice Aide
PH15
PH16
Volunteers
Employees
Volunteers
B.
A.
B.

Licensed Practical Nurses/
Licensed Vocational Nurses PH13
Employees
Volunteers
A.
B.
Counselors
PH17
Employees
Volunteers
A.
B.

Medical Social Workers
Employees
A.
Others
Employees
A.

PH14
Volunteers
B.

Total Number

Employees
PH18
Volunteers
A.
B.

PH19
Volunteers
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 (08/10)

PART 2 – REGIONAL OFFICE

PART 3 – STATE AGENCy

PART 4

PART 5 – PROVIDER