DEPARTMENTOF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES REQUEST FOR SURVEY OF 489.20 AND 489.24 ESSENTIALS OF PROVIDER AGREEMENTS: Responsibilities of Medicare Participating Hospitals in Emergency Cases 1. Name and Address of State Agency 2. Name and Address of Hospital 3. Provider Number RO Complaint Control Number4. Hospital Accredited By:  JCAHO  AOA  Nonaccredited DO NOT INFORM THE HOSPITAL OF THE SURVEY 5. In Complaint Cases, Type of Emergency (check all that apply)  Labor  Other OB  Medical  Trauma  Psychiatric  Surgical  Other6. Source of Complaint (check all that apply)  Patient or Patients Family  Quality Improvement Organization  Receiving Hospital  Medicare Intermediary  Transferring Hospital  Other (specify)  Congressional Inquiry 7. In Complaint Cases, Type of Complaint (check all that apply)  Physician on-call list  Policies/Procedures  Transfer  Screening  Treatment  Posting of Signs  Medical Records  Reporting Requirement  Whistleblower  Recipient Hospital Responsibilities  Delay in Examination or Treatment  Central LogA copy of the allegation is enclosed.The name of the complainant should not be disclosed without specific authorization. Due to the serious nature of this complaint,please conduct the survey within 5 working days of notification. Signature of Regional Administrator or Designee Region Date Form CMS -1541A(4-95)