Form CMS-370 Health Insurance Benefits Agreement

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB No. 0938-0266

HEALTH INSURANCE BENEFITS AGREEMENT (CMS-370)
(AGREEMENT WITH AMBULATORY SURGICAL CENTER PURSUANT TO
SECTION 1832(a)(2)(F) OF THE SOCIAL SECURITY ACT)

For the purpose of establishing eligibility for payment under title XVIII of the Social Security Act,
(Insert Name of Facility),

hereinafter referred to as the Ambulatory Surgical Center, hereby agrees:

to maintain compliance with the conditions set forth in part 416 of chapter IV, title 42 of the Code
of Federal Regulations, and to report promptly to the Centers for Medicare & Medicaid Services
(CMS) any failure to do so;
(B) not to charge a Medicare beneficiary or any other person for items or services for which the
beneficiary is entitled to have payment made in accordance with part 416 of chapter IV, title 42
of the Code of Federal Regulations;
(A)

to refund as promptly as possible any money incorrectly collected from beneficiaries or from someone
on his or her behalf;
(D) to furnish to CMS, if requested, information necessary to establish payment rates specified in
§416.120 and §416.130 in the form and manner that CMS requires;
(E) to accept assignment for all facility services furnished in connection with covered surgical
procedures as specified in §416.85; and
(F) to comply with statutory and regulatory requirements regarding revision of the Quality
Improvement Organization that contracts with CMS to review ambulatory surgical
procedures.
(C)

This agreement, upon submission by the Ambulatory Surgical Center and upon acceptance for filing by
the Secretary of Health and Human Services, shall be binding on the Ambulatory Surgical Center and
the Secretary. The agreement may be terminated by either party in accordance with regulations. In the
event of termination, payment will not be available for Ambulatory Surgical Center services furnished
on or after the effective date of termination.

This agreement shall become effective on the date specified below by the Secretary or the Secretary’s
delegate, and shall remain in effect unless terminated. In the event of a transfer of ownership of the
Ambulatory Surgical Center, this Agreement Shall Remain Effective as between the Secretary of
Health and Human Services and the Transferee.
ATTENTION: Read the following provision of Federal law carefully before signing.

Whoever, in any matter within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact,
or make any false, fictitious or fraudulent statement or representation, or makes or uses any false
writing or document knowing the same to contain any false, fictitious or fraudulent statement, or
entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both (18 U.S.C.
section 1001).
CMS-370 / Expires XX/XX/XXXX

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB No. 0938-0266

HEALTH INSURANCE BENEFITS AGREEMENT (CMS-370)
(AGREEMENT WITH AMBULATORY SURGICAL CENTER PURSUANT TO
SECTION 1832(a)(2)(F) OF THE SOCIAL SECURITY ACT)

Accepted for the Ambulatory Surgical Center by:

Accepted for the Secretary of Health and Human
Services by:

Printed Name:

Printed Name:

Signature:

Signature:

Date:

Date:

Effective Date of Agreement:

PRA Disclosure Statement
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 0938-0266 (Expires XX/XX/XXXX). The time required to complete this information
collection is estimated to average 1 hour 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: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850. ****CMS Disclosure**** 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 CMS as
[email protected] .

Form CMS-370 / Expires XX/XX/XXXX

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