Form Cms-1541b - Responsibilities Of Medicare Participating Hospitals In Emergency Cases Investigation Report

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS &
CRITICAL ACCESS HOSPITALS (CAHS) IN EMERGENCY CASES
INVESTIGATION REPORT
1. Name of Facility
2. Street Address
3. City and/or County
4. State
5. ZIP Code
6. CMS Certification No.
7. Name of CEO and CEO email address
8. Telephone Number
9. State/Region Code
10. State/Country Code
11. Dates of Survey
_____ / _____ / __________
to
_____ / _____ / __________
12. Medicare No. of Certified Beds
13. ACTS Complaint Intake No.
14. Type of Survey
Complaint
Revisit
15. SA Recommendation:
In Compliance - No Further Action
In Compliance but previously Out of Compliance
(choose for self-reported allegations only)
Recommend Termination (23 Day)
Possible Discrimination - refer to OCR
Recommend Termination (90 Day)
For Complaint Survey: I certify that I have reviewed the requirements of 42 CFR 489.24 and the related provisions of
42 CFR 489.20 and, unless indicated otherwise on the related Form CMS 2567, the facility was found to be in compliance with the regulations.
Signature
Title
Date
Signature
Title
Date
For Revisit: For the purpose of a revisit, I certify that I have reviewed the facility’s current compliance with the requirements for which they were
not in compliance during the survey on
and unless indicated otherwise on the related Form
CMS 2567, the facility was found to be in compliance with those requirements.
Signature
Title
Date
Signature
Title
Date
Form CMS-1541B (Exempt)

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