Crosswalk

Revisions to CMS-417 - HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM c

Previous Page #	Current Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
1	1	Instructions	Reformat instructions	Font of Instructions increased from 8 to 11.	In the current version of the CMS-417 form, the instructions are printed in size 8 font. This is very small text which is very hard to read and understand. We have increased the size of the font to size 11 to make the instructions more readable. This change does not add any additional burden.
1	3	PRA Disclosure Statement	PRA Disclosure Statement moved from instruction page to the end of the CMS-417 form on page 3	The PRA disclosure statement was moved from right after the instructions to after the CMS-417 form on page 3.	After increasing the font of the instructions to 11, there was no room for the PRA disclosure statement on the instructions page. We believe that the PRA disclosure statement should be placed at the end of the data collection form. Therefore, we relocated this statement to page 3, after the CMS-417 form. This change does not add any additional burden.
1	2-3	CMS-417 data collection fields	Font for PRA data collection fields increased	The font for the text of the CMS-417 form was increased from 8 to 11.	In the current version of the CMS-417 form, the data collection fields are all squished onto 1 page. To fit all of these multiple data collection fields onto 1 page, a font of 8 was used. This makes the form difficult to view and read. There is no reason for the CMS-417 for to be contained to 1 page. There is no statutory limit on the number of pages a data collection form can have. In fact, it is in the best interest of the entity that must respond to the form to be able to easily read and understand the form to which they must respond. We have increased size of each text box and have increased the text font to 11. This has caused the CMS-417 form to be spread over 2 pages and makes this form much more readable and user friendly. These changes do not add any additional burden.
1	2	IV. Services Provided	Section moved to new page 2	Section moved to new page 2	The reformatting of the CMS-417 form has caused this section to be moved to a new second page. This change does not add any additional burden.
1	2	Number of Employees	Section reformatted and moved to new page 2	This section was reformatted so that the data fields are situated vertically instead of horizontally. Section moved to new page 2	In the current version of the CMS-417 form, the data collection fields for section V are spread out horizontally and for each data field there are 2 separate sub sections. This layout along with the small text font size makes it very difficult to read and understand this section. We have reformatted this section by rearranging these data sections horizontally and used 11 font. This makes this section much easier to read and understand. The reformatting of the CMS-417 form has caused this section to be moved to a new second page. These changes do not add any additional burden.
1	2	Attestation Statement	Title of “Attestation Statement” added Section moved to new page 2	The title “Attestation Statement” was added This section was moved to new page 2	In the current version of the CMS-417 form, the attestation statement was inserted without any identification or title stating what this language is. We believe that it is important that the signer of the form understands the nature of the statement to which they are agreement and acknowledging when they sign the CMS-417 form. Therefore, we have added the title “Attestation Statement” above this sentence. The reformatting of the CMS-417 form has caused this section to be moved to a new second page. These changes do not add any additional burden.