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 (CMS-377)
(Please read the following instructions before completing
this form)

INSTRUCTIONS
•

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.

•

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/RegionalOfices/

•

Detailed instructions are given for questions other than those considered self-explanatory.

•

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

CMS-377 / Approved XX/XX/XXXX

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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 (CMS-377)
(Please read the following instructions before completing this form)
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
(Place '1', '2' or ‘3’ in blocks)

Non-Profit

2.

ASS

2.

Radiology

3.
3.

Government
Pharmaceutical Services

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

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 30 minutes 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].

CMS-377 / Expires XX/XX/XXXX

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