CMS-216-94 Organ Procuremnet Organization/Histocompatibility Labora

06-15
Form CMS-216-94
This report is required by law (42 USC 1395g) and 42CFR 413.20 and 413.24.
Failure to report can result in all payments made during the reporting period
being deemed overpayments (42 USC 1395g).
ORGAN PROCUREMENT ORGANIZATION
Provider CCN:
PERIOD:
HISTOCOMPATIBILITY LABORATORY GENERAL_______________ FROM:_______
DATA AND CERTIFICATION STATEMENT
TO:__________
Contractor Use Only:
Date Received _____________[ ] Initial
[ ] Audited
Contractor No. ____________ [ ] Final
[ ] Desk Reviewed
PART I - GENERAL
Check
[ ] Electronic filed cost report
applicable box
[ ] Manually submitted cost report
1 Name:
Provider CCN:
1 Street:
P.O. Box:
1 City:
State:
Zip Code:
2 Name:
Provider CCN:
2 Street:
P.O. Box:
2 City:
State:
Zip Code:
3 Reporting Period: From
To
Type of Control
(see instructions)
2

1

Type of Provider
(see instructions)
3

3390(Cont.)
FORM APPROVED
OMB NO. 0938-0102
Expires: 09/30/2020
WORKSHEET
S

[

] Re-opened

Date:
Time:
1
1
1
2
2
2
3

Participation Date
4

4
4
PART II-CERTIFICATION BY OFFICER OR ADMINISTRATOR OF FACILITY
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY
BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT
UNDER FEDERAL LAW. FUTHERMORE, IF SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED
OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWIS
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATION ACTION, FINES AND/OR IMPRISONMENT MAY RESULT
CERTIFICATION BY OFFICER, ADMINISTRATOR OR DIRECTOR OF ORGANIZATION/LABORATORY
I HEREBY CERTIFY that I have read the above cerification statement and that I have examined the accompanying electronically filed
or manually submitted cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by
_________________(Provider name(s) and CCN(s) for the cost reporting period beginning _____________________ and
ending_________________________, and that to the best of my knowledge and belief, this report and statement are true, correct,
complete and prepared from the books and records of the OPO/LAB in accordance with applicable instructions, except as noted.
I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that the services
identified in this cost report were provided in compliance with such laws and regulations.

(Signed) ______________________________________________
Officer, Administrator or Director
______________________________________________
Title
______________________________________________
Date
PART III - SETTLEMENT SUMMARY
TITLE XVIII
Organ Acquisition
Tissue Typing
1
2
1 OPO/LAB

1

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 0938-0102. The time required to complete
this information collection is estimated to average 45 hours 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 comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form please write to: Centers for Medicare and Medicaid Services, 7500 Security
Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, 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 1-800-MEDICARE.

FORM CMS-216-94 (06-2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2,
SECTIONS 3302, 3302.1 and 3302.2)
Rev. 6

33-303