DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB No.0938-0313 INSTRUCTIONS FOR COMPLETING HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM STATEMENT CONCERNING INFORMATION COLLECTION REQUIREMENTS AND USES: This form is required to obtain or retain Medicare benefits. It serves two purposes. First, it provides basic information about the Hospice which is necessary for the State to properly schedule a survey. Second, it provides a data-base necessary for responding to questions frequently asked by Congress, Federal agencies, and interested members of the public. Submission of this form will initiate the process of obtaining a decision as to whether the Conditions are met. Answer all questions as of the current date. Complete and return this form to your State Agency (found at https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/downloads/state_agency_contacts.pdf), and retain a copy for your files. Detailed instructions are given for questions other than those considered self-explanatory. Item I: · Request to establish eligibility in--current Hospice Benefits are available only through the Medicare program. · · · Medicare certification number: Insert the facility's six digit Medicare Certification Number. Leave blank on initial requests for certification. State/County and State/Region Codes: Leave blank. The Centers for Medicare & Medicaid Services Regional Office will complete. Related certification number: If Hospice is affiliated with any other type Medicare provider, insert the related facility's six digit Medicare Certification Number. Item IV: · If a service is provided directly by the facility place a "1" the appropriate block. · · If a service is provided through an outside source (i.e., by contract/arrangement), place a "2" in the appropriate block. If a service is provided both directly and through arrangement, place a "3" in the appropriate box. 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 0938-0313. The time required to complete this information collection is estimated to average 15 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB No. 0938-0313 HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM (Read Instructions and Information Collection Statement On Cover Sheet of Form Prior to Completion) I. Identifying Information Name of Hospice Street Address Request to Establish Eligibility In 1. Medicare State/County PH2 PH3 PH1 Medicare/Certification Number City, County and State State/Region PH4 For Hospitals Only (Check One) The Joint Commission Accredited A. B. AOA Accredited C. Both The Joint Commission and AOA Accredited D. Non-Accredited Proprietary: 4. 5. 6. 7. 2. Individual Partnership Corporation Other Nursing Services Government: 8. 9. 10. 11. 3. State County City City-County Medical Social Services 12. 13. Telephone Number (include area code) PH5 Zip Code Related Certification Number PH6 Fiscal Year Ending Date II. Type of Hospice (Check One) 1. 2. 3. 4. PH7 5. 1. 2. 3. Hospital Skilled Nursing Facility Intermediate Care Facility Home Health Agency Freestanding Hospice Church Private Other III. Type of Control (Check One) PH8 Non-Profit: Combination Government and Nonprofit Other IV. Services Provided: By staff, place a "1" in the block(s) If under arrangement, place a "2" in the block(s) If by staff and arrangement, place a "3" in the block(s) Core: 1. Physician Services 5. 6. 7. 8. 9. 10. 11. 12. Physical Therapy Occupational Therapy Speech-Language Pathology Hospice Aide Homemaker Medical Supplies Short Term lnpatient Care Other(Specify) 4. Counseling Services Name and Address of Contractee Medicare Certification/Supplier Number PH9 PH1O A. ______Acute B. ______Respite Licensed Practical Nurses/ Licensed Vocational Nurses PH13 Employees Volunteers A. B. Counselors PH17 Employees Volunteers A. B. Medical Social Workers Employees A. Others Employees A. PH14 Volunteers B. Total Number V. Number of Employees/ Volunteers Full-time Equivalent Top section of professional category reflects total number of FTE (i.e., PH 11 through PH 18) Physicians Employees A. Homemakers Employees A. Registered Professional Nurses PH11 PH12 Volunteers Employees Volunteers B. A. B. Hospice Aide PH15 PH16 Volunteers Employees Volunteers B. A. B. PH19 Volunteers B. Employees PH18 Volunteers A. B. Whoever knowingly or willfully makes or causes to be made a false statement or representation on this form may be prosecuted under applicable Federal or State laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate, or where the entity already participates, a termination of its agreement or contract with the State agency or the Secretary as appropriate. Name of Authorized Representative and Title (Typed) Signature Date PH20 Form CMS-417 (12/15) American LegalNet, Inc. www.FormsWorkFlow.com