Emergency and Foreign Hospital Services and Supporting Regulation in 42 CFR Section 424.103 (CMS-1771)

This form is used in connection with claims for emergency hospital services provided by hospitals that do no have an agreement in effect under Section 1866 of the Social Security Act. 42 CFR 424.103 (b) requires that before a non-participating hospital may be paid for emergency services rendered to a Medicare beneficiary, a statement must be submitted that is

The latest form for Emergency and Foreign Hospital Services and Supporting Regulation in 42 CFR Section 424.103 (CMS-1771) expires 2023-06-30 and can be found here.