Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)

The CMS-370 Health Insurance Benefits Agreement is utilized for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. No edits were made to this agreement form. The CMS-377 ASC Request for Certification or Update of Certification Information in the Medicare Program form is utilized to collect facility-specific characteristics that facilitate CMS’ oversight of ASCs, for example, through the ability to track and trend survey results broken down by various facility characteristics. The data also enables CMS to respond to inquiries from the Congress, GAO, OIG concerning the characteristics of Medicare-participating ASCs. This form is submitted by ASCs when they request initial certification of compliance with the ASC CfCs or to update an ASC’s existing certification information. Minor edits to form were made for clarification of data being requested.

The latest form for Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370) expires 2021-02-28 and can be found here.