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pdfDEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
________________________________________________________________________________________________________________________________________________________________________________
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM (CMS-417)
INSTRUCTIONS
This form is required to obtain or retain Medicare benefits. It serves two purposes. First, it provides basic information about the Hospice which is
necessary for the State to properly schedule a survey. Second, it provides a data-base necessary for responding to questions frequently asked by
Congress, Federal agencies, and interested members of the public.
Submission of this form will initiate the process of obtaining a decision as to whether the Conditions are met.
Answer all questions as of the current date. Complete and return this form to your State Agency (found at
https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/downloads/state_agency_contacts.pdf), and retain a copy for your files.
Detailed instructions are given for questions other than those considered self-explanatory.
Item I:
•
Request to establish eligibility in:
Current Hospice Benefits are available only through the Medicare program.
•
•
•
Medicare certification number:
Insert the facility’s six digit Medicare Certification Number. Leave blank on initial requests for certification.
State/County and State/Region Codes:
Leave blank. The Centers for Medicare & Medicaid Services Regional Office will complete.
Related certification number:
If Hospice is affiliated with any other type Medicare provider, insert the related facility’s six digit Medicare Certification Number.
Item IV:
•
If a service is provided directly by the facility place a “1” the appropriate block.
•
•
If a service is provided through an outside source (i.e., by contract/arrangement), place a “2” in the appropriate block.
If a service is provided both directly and through arrangement, place a “3” in the appropriate box.
CMS-417 / Expires XX/XX/202X
Instructions
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
________________________________________________________________________________________________________________________________________________________________________________
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM (CMS-417)
I.
Identifying
Information
Name of Hospice:
Street Address:
Request to Establish Eligibility In Request to Establish
Eligibility In Medicare
City, County & State:
Yes
No
Medicare Certification No. (CCN)
II. Type of
Hospice
(Check One)
(PH7)
III. Type of
Control
(Check One)
Hospital
State/County
(PH2)
(PH1)
(PH3)
Skilled Nursing Facility
Intermediate Care Facility
Home Health Facility
Free-standing Hospice
Region/State
Name of Accrediting Organization
(For Hospitals Only) (Check One)
Non-Accredited
8. State
3. Other
6. Corporation
10. City
CMS-417 / Expires XX/XX/202X
(PH6)
Fiscal Year Ending
Date
The Joint Commission (TJC)
4. Individual
7. Individual
Related Certification
Number
Community Health Accreditation Partner(CHAP)
1. Church
(PH8)
(PH5 )
Accreditation Commission for Healthcare (ACHC)
Proprietary
5. Partnership
Telephone Number
(10 digit)
(PH4)
Non-Profit
2. Private
Zip Code:
Government
9. County
Government (cont.)
12. Combination Government & Nonprofit
13. Other
11. City-County
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
________________________________________________________________________________________________________________________________________________________________________________
IV. Services
Provided:
•
•
•
If by staff, place a “1”
in the block(s)
If under arrangement,
place a “2” in the
block(s)
If by staff and
arrangement, place a
“3” in the block(s)
CORE:
1. Physician Services
5. Physical Therapy
Employees –
(Including FullTime
Volunteers
(Top section of
professional category
reflects total number
of FTE (i.e., PH 11
through PH 18))
3. Medical Social Services
Name & Address of Contractee
6. Occupational Therapy
4. Counseling Services
Medical Certification / Supplier Number
7. Speech Language Pathology
8. Hospice Aid
9. Homemaker
10. Medical Supplies
11. Short Term Inpatient Care
12. Other (Specify)
(PH10)
V. Number of
2. Nursing Services
A._____ Acute
B. _____ Respite
Job Title
Physicians (M.D. or D.O.
Number of Employees
Number of Full-Time
Volunteers
(PH11)
Registered Nurses (R.N.s)
(PH12)
Medical Social Workers
(PH14)
Hospice Aides
(PH16)
Others
(PH18)
Licenses Practical or Vocational Nurses
(L.P.N or L.V.N)
(PH13)
Homemakers
Counselors
TOTAL NUMBER
CMS-417 / Expires XX/XX/202X
(PH15)
(PH17)
(PH19)
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
________________________________________________________________________________________________________________________________________________________________________________
Attestation Statement
Whoever knowingly or willfully makes or causes to be made a false statement or representation on this form may be prosecuted under applicable
Federal or State laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a
request to participate, or where the entity already participates, a termination of its agreement or contract with the State agency or the Secretary as
appropriate.
Printed or Types Name of Person at Facility Completing Form
Signature
Date CMS-417 form Completed
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 0938-0313 (Expires XX/XX/202X). This is a mandatory information
collection. The time required to complete this information collection is estimated to average 45 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 Thomas Pryor at [email protected].
CMS-417 / Expires XX/XX/202X
Page 3
| File Type | application/pdf |
| Author | CAROLINE GALLAHER |
| File Modified | 2021-03-02 |
| File Created | 2021-03-02 |