CMS-377 Ambulatory Surgical Center Request for Initial Certifica

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

Form Approved

0MB No. 0938-0266

AMBULATORY SURGICAL CENTER REQUEST FOR INITIAL CERTIFICATION
OR UPDATE OF CERTIFICATION INFORMATION IN THE MEDICARE PROGRAM
(Please 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 for Coverage are met. Assistance in completing the form is available
from the State agency. The ASC completes and signs this form for initial certifications
and upon request of the State agency for the periodic recertification .

CMS Certification Number (CCN): Insert the facility's ten-digit CCN. Leaveblank on

initial requests for certification.

State/County and State Region Codes:The ASC leaves this blank.
Item Ill: If a service is provided directly by the facility, place a ' 1' 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 appropriate Regional
Office. Please see the following link for additional information:
http://www.cms.gov/RegionalOf ices/

If a service is provided under an arrangement with an outside source, place a '2' in the

appropriate block. If the service is provided in combination, place a ‘3’ in the appropriate block.

If the service is not provided, leave blank.

Item IV: Place an 'X' in the appropriate blocks representing categories of surgery

offered by the ASC. Under "Other," include only broad categories (i.e., not

subspecialties). More than one block may be checked.

Detailed instructions are given for questions other than those considered
self-explanatory.
State/County Code

CMS Certification Number

State Region Code

AS1

AS2

Name of Facility

I. IDENTIFYING
INFORMATION

AS3

Street Address

City, County, and State

Telephone No. (Include Area Code)

Zip Code

AS4

II. TYPE OF CONTROL

1.

Proprietary

1.

Laboratory

IV. SURGICAL
SPECIALTIES

1.

Dental

4.

Ob/Gyn

7.

Pain

(X appropriate blocks)

2.

Endoscopy

5.

Ophthalmologic

8.

Plastic/reconstructive

3.

Ear/Nose/Throat

6.

9.

Podiatry

(Check one box)

Ill. ANCILLARY
SERVICES

Non-Profit

2.

ASS

2.

Radiology

3.
3.

Government
Pharmaceutical Services

(Place '1', '2' or ‘3’ in blocks)
AS6

AS7

V. FACILITY
CHARACTERISTICS

Orthopedic

1. Number of Operating Rooms/Procedure Rooms ______

10.

Other(Specify)

2. Date Center Began Providing Services

/

/

ASS

AS9

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.
Signature of Authorized Official (sign in ink) (required only for initial certification)

Title

Date
AS10

According to the Paperwork Reduction of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB 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. Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you
have questions or concerns regarding where to submit your documents, please contact the appropriate CMS Survey and Certification Regional Office contact based upon the State in which your Ambulatory Surgical Center is located. Regional Contacts are listed at the following
website link https://www.cms.gov/About-CMS/Agency-Information/RegionalOffices/index.html?redirect=/regionaloffices/ Expiration Date: XX/XX/XXXX

Form CMS-377