1
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Part
1
Items
#1 to #12
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Add
fillable text or check blocks to items #1 to 12.
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Fillable
text and check boxes were added to items #1 to #12 so that the
HHAs can type in the required information.
|
A
previous version of the CMS-1572 form was in a .pdf fillable
format. However, when it was revised in the past, the revised
form was not a fillable .pdf.
We
have made these items fillable so that the HHA staff can complete
the form electronically. This will allow the HHA staff to submit
the form electronically without having to complete the form by
hand to typewritten and then having to scan the form.
Also,
having a fillable .pdf form will allow the CMS Locations to
electronically export the information from the form instead of
manually inputting the information into the system.
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1
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Item
#7
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Add
an additional selection for item #7 Type of Control, titled “03
Non-Profit”.
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We
have added an additional selection to item #7 - Type of Control.
This
selection is:
“03
Non-Profit”
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When
the CMS-1572 form was revised with the previous PRA package, the
number of response selections for this item (was item #17 on the
previous version of the form) were reduced from 7 to 2.
These
2 existing selections are:
01
– Proprietary
02
– Government Operated
However,
there are many non-profit HHAs. The non-profit HHAs do not fit
under either of the existing 2 categories for the following
reasons:
Therefore,
it is necessary to add the additional category of “03
Non-Profit”
to item #7.
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1
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Name
of Person Completing Form
|
Add
a fillable text block.
|
A
fillable text block was added so that the person completing the
CMS-1572 form can type in their name.
|
A
previous version of the CMS-1572 form was in a .pdf fillable
format. However, when it was revised in the past, the revised
form was not a fillable .pdf.
We
have made these items fillable so that the HHA staff can complete
the form electronically. This will allow the HHA staff to submit
the form electronically without having to complete the form by
hand to typewritten and then having to scan the form.
Also,
having a fillable .pdf form will allow the CMS Locations to
electronically export the information from the form instead of
manually inputting the information into the system.
|
1
|
Date
Form Completed
|
Add
a fillable text block.
|
A
fillable text was block added so that the completing the CMS-1572
form can type in the date the form was completed.
|
A
previous version of the CMS-1572 form was in a .pdf fillable
format. However, when it was revised in the past, the revised
form was not a fillable .pdf.
We
have made these items fillable so that the HHA staff can complete
the form electronically. This will allow the HHA staff to submit
the form electronically without having to complete the form by
hand to typewritten and then having to scan the form.
Also,
having a fillable .pdf form will allow the CMS Locations to
electronically export the information from the form instead of
manually inputting the information into the system.
|
2
|
Part
2
Sections
13 & 14
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Add
fillable text blocks
|
Fillable
text and check boxes were added to each of these data fields so
that the HHAs can type in the required information.
|
A
previous version of the CMS-1572 form was in a .pdf fillable
format. However, when it was revised in the past, the revised
form was not a fillable .pdf.
We
have made these items fillable so that the HHA staff can complete
the form electronically. This will allow the HHA staff to submit
the form electronically without having to complete the form by
hand to typewritten and then having to scan the form.
Also,
having a fillable .pdf form will allow the CMS Locations to
electronically export the information from the form instead of
manually inputting the information into the system.
|