CMS-10237 CY 2018 Medicare Advantage Facility HSD Table

Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application Regulations under 42 CFR 422 (Subpart K) & 417.400 (CMS-10237)

CY2018 CMS MA Facility HSD Table 10-20-16

Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application

OMB: 0938-0935

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0935 can be found here:

2022-10-13 - Revision of a currently approved collection
2020-01-07 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

CY 2018 MA Facility HSD Table

SSA State/County
Code

Facility or Service
Type

Specialty Code

National Provider
Identifier (NPI) Number

OMB Control Number: 0938-0935 (Expires: TBD)

# of Staffed, MedicareCertified Beds

Facility Name

Provider Service
Street Address

Provider Service City

Provider Service
State

Provider Service Zip
Code

Uses CMS MA Contract
Amendment (Y or N)

File Type	application/pdf
File Title	HSD Table Templates
Author	CGI Federal
File Modified	2016-10-20
File Created	2016-10-13