CMS-377 Ambulatory Surgical Center Request for Initial Certifica

Department Of Health and Human Services
Centers For Medicare & Medicaid Services

Form Approved
OMB No. 0938-0266

Ambulatory Surgical Center Request for Initial Certification or
Update of Certification`Information in the Medicare Program

(CMS-377)

CMS Certification Number:

State/County Code:

State/Region Code:

AS1

I. Identifying
Information

AS2

Name of ASC:

Street Address;

City, State:

Zip Code:

AS3

Telephone Number (10 digits):
AS4

II. Type of Control
(Check only one box)

Proprietary

Government

Non-Profit

AS5

III. Ancillary Services
(Select only one item from
the dropdown menu for each
service listed)
AS6

IV. Surgical
Specialties

(Check all that apply)

AS7

V. Facility
Characteristics

Laboratory Services

Radiology Services

Pharmaceutical Services

Select one of the following options Select one of the following options
1. Dental

4. OB/GYN

2. Endoscopy

5. Ophthalmologic

8. Podiatry

3. Ear, Nose & Throat

6. Orthopedic

9. Plastic/Reconstruction

A. Number of Operating Rooms:

B. Number of Procedure Rooms:

CMS-377 / OMB Approval Expires XX/XX/20XX

7. Pain

Select one of the following options
10. Other (Specify)

Other Specify:

C. Date this ASC began providing services:
AS8

AS9

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Department Of Health and Human Services
Centers For Medicare & Medicaid Services

Form Approved
OMB No. 0938-0266

Ambulatory Surgical Center Request for Initial Certification or
Update of Certification`Information in the Medicare Program

(CMS-377)

ATTESTATION STATEMENT
I hereby certify that the responses in this form are true and correct to the best of my knowledge, information and belief. 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.
Printed Name of ASC Representative:

Title of ASC Representative:

Signature of ASC Representative:

Date Signed by ASC Representative:
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/20XX). This is a mandatory
information collection. 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 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 Caroline Gallaher at [email protected].

CMS-377 / OMB Approval Expires XX/XX/20XX

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Department Of Health and Human Services
Centers For Medicare & Medicaid Services

Form Approved
OMB No. 0938-0266

Ambulatory Surgical Center Request for Initial Certification or
Update of Certification`Information in the Medicare Program

(CMS-377)

INSTRUCTIONS
1. Submission of this form will initiate the process of obtaining a decision as to whether the Conditions for Coverage are met.
2. Assistance in completing the form is available from the State Survey agency for area in which the ASC is located.

3. The ASC must complete and sign the CMS-377 form for initial certifications and upon request of the State agency for the periodic
recertification.

4. Answer all questions as of the current date.

5. Return the original and two copies of the completed CMS-377 form to the State Survey Agency. Retain a copy for your files.

6. The name and address of the State Survey agency for the area in which the ASC is located may be obtained from the appropriate CMS Location
(formerly called CMS Regional Office). Please see the following link for additional information: http://www.cms.gov/RegionalOfices/

7. CMS Certification Number (CCN): Insert the facility's ten-digit CCN. Leave blank on initial requests for certification.
8. State/County and State Region Codes: - The ASC should leave these fields blank.
9. For Item Ill:

a. If a service is provided directly by the facility, select “1” from the drop down list.

b. If a service is provided by an outside source by arrangement with the facility, select “2' from the drop down list.

c. If the service is provided by both the facility and an outside source by arrangement with the facility, select “3” from the drop down list.

d. If the service is not provided, do not make a selection.

10. For 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 / OMB Approval Expires XX/XX/20XX

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