CMS-R-138 Statewide Affidavit

HOSPITAL AFFIDAVIT FOR STATEWIDE WAGE INDEX RECLASSIFICATION
State of
County or parish of
I,
being duly sworn, depose and say as follows:

(type or print name),

(1)

I certify that
(Provider’s name and Medicare provider number) (“the hospital”) agrees to be included in the
statewide wage index reclassification request for the State of
for the federal fiscal years 2018 through 2020 (October 1, 2017 to September 30, 2020).

(2)

I understand that all prospective payment system hospitals in the state must apply as a group
for reclassification to a statewide wage index through a signed single application.

(3)

I understand that all prospective payment system hospitals in the state must agree to the
reclassification to a statewide wage index through a signed affidavit on the application.

(4)

I understand that all prospective payment system hospitals in the state must agree, through
an affidavit, to withdrawal of an application or to termination of an approved statewide wage
index reclassification.

(5)

I understand that the hospital waives its rights to any wage index classification that it would
otherwise receive absent the statewide wage index classification, including a wage index that
it might have received through individual geographic reclassification.

(6)

I certify that I am an officer of the hospital or a corporate officer of the hospital’s parent
corporation with authority to sign this affidavit for the hospital’s inclusion in the statewide
wage index reclassification request.
Signature:
Title:
Phone number:
E-mail address:

Subscribed and sworn to before me
This

day of

Notary Public

My commission expires:

Expires 7/31/2020

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