CMS-276 Index and Instruction

CHAPTER 11
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
FORM CMS-339
Section
General
General……………………………………………………………………… 1100
Filing Requirements of Provider Cost Report
Reimbursement Questionnaire……………………………………………. 1100.1
Instructions
Instructions for Form CMS-339 (Provider Cost Report
Reimbursement Questionnaire)…………………………………………… 1102
Exhibit 1 - General Provider Information………………………………… 1102.1
Certification by Officer or Administrator of
Provider…………………………………………………………………… 1102.2
Reimbursement Information……………………………….……………… 1102.3
Exhibits
Exhibit 1
Exhibit 2

Rev. 6

-

Provider Cost Report Reimbursement Questionnaire (6 pages)
Listing of Medicare Bad Debts and
Appropriate Supporting Data

11-1