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pdfDEPARTMENT OF HEALTH AND HUMAN
SERVICES CENTERS FOR MEDICARE & MEDICAID
FORM APPROVED
OMB NO. 0938-0378
MEDICARE/MEDICAID PSYCHIATRIC HOSPITAL SURVEY DATA (CMS-724)
__________________________________________________________________________________________________________________________________________
SECTION I: To be completed by the hospital
Street Address
Name of Hospital
B2
B1
Hospital Provider Number
City or County
Total Number of Beds
State
ZIP Code
B4
B3
Total Number of Certified Beds
Other Data — Does the hospital operate a forensic unit?
Yes
For the past year: A. Total number of admissions to certified areas
from (month)
(year)
MEDICARE/Part A
B9
B. Age Range of Patients
B10
C. Medicare/Medicaid Billings
Billed
Collected
B11
D. Other Data — Does the hospital operate a separate MEDICAID
ONLY-Residential Treatment Program for
Psychiatric patients under the age of 22?
Yes
MEDICARE/Part B
No
B8
B7
B6
No
B12
MEDICAID
13. Current Hospital Statistics (on days of survey) [certified beds only]
Name of Ward
Bed Capacity
Patient Census
Total Patient Census
Form CMS-724
B5
B13
Page 1
DEPARTMENT OF HEALTH AND HUMAN
SERVICES CENTERS FOR MEDICARE & MEDICAID
FORM APPROVED
OMB NO. 0938-0378
MEDICARE/MEDICAID PSYCHIATRIC HOSPITAL SURVEY DATA (CMS-724)
__________________________________________________________________________________________________________________________________________________________________
SECTION II: To be completed by the survey team
Dates of Survey (beginning)
(mm)
/
(day)
/
(year)
Dates of Survey (ending date)
(mm)
B14
Survey Team Composition
Administrator
Nurse
Dietician
Pharmacist
Social Worker
LSC Specialist
Sanitarian
Physician
Psychologist
Other
/
(day)
/
(year)
Type of Survey: Initial (B16)
Complaint (B19)
B15
Total Number of Surveyors on Site
(B22)
SA
(B32)
(B23)
RO
(B33)
Consultant
(B34)
CO
(B35)
(B24)
(B25)
(B26)
Recertification (B17)
Follow-up (B18)
Second Follow-up (B20)
Concurrent
with General
Hospital
(B21)
(B27)
(B28)
(B29)
(B30)
(B31)
Total Number of Surveyors on Site
(B36)
19. Certification of Findings
I certify that I have reviewed each Condition of Participation and Related Standards for Psychiatric Hospitals, and unless indicated on the CMS-2567, the
Facility was found to be in compliance with the Conditions and/or Standards.
Signature
Title
Date
Signature
Title
Date
Signature
Title
Date
Signature
Title
Date
Signature
Title
Date
Form CMS-724
Page 2
DEPARTMENT OF HEALTH AND HUMAN
SERVICES CENTERS FOR MEDICARE & MEDICAID
FORM APPROVED
OMB NO. 0938-0378
MEDICARE/MEDICAID PSYCHIATRIC HOSPITAL SURVEY DATA (CMS-724)
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 0938-0378 (Expires XX/XX/202X). 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 any 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, C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****
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 [email protected].
Form CMS-724
Page 3
| File Type | application/pdf |
| File Title | CMS-724 |
| Author | CMS |
| File Modified | 2021-02-19 |
| File Created | 2021-02-19 |