Form Cms-437a - Rehab Unit Criteria Worksheet printable pdf download

Form Cms-437a - Rehab Unit Criteria Worksheet

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0986

REHABILITATION UNIT CRITERIA WORK SHEET

RELATED MEDICARE PROVIDER NUMBER

ROOM NUMBERS IN THE UNIT

FACILITY NAME AND ADDRESS (City, State, Zip Code)

NUMBER OF BEDS IN THE UNIT

SURVEY DATE

REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD

VERIFIED BY

MM DD YYYY

ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM

MEDICARE’S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM OR FROM THE PAYMENT SYSTEM USED TO PAY CRITICAL ACCESS HOSPITALS.

THE HOSPITAL REPRESENTATIVE WHO

TAG

REGULATION

GUIDANCE

YES

N/A

COMPLETES THIS ENTIRE FORM

• Verification of hospital attestations may be done

The hospital representative is expected to answer all

by CMS surveyors or MACs as applicable.

questions accurately.

The representative should verify the answers with

the director of rehabilitation, physician, medical

records office, or any applicable department to

ensure correct responses to this form.

A “yes” response means the hospital is in

compliance with the applicable regulation.

§412.25 Excluded hospital units: Common

requirements.

(a) Basis for exclusion. In order to be excluded

In the case of § 412.25 and § 412.29, as related to

from the prospective payment systems specified in

IRF units, the term hospital includes Critical Access

§412.1(a)(1), a rehabilitation unit must meet the

Hospitals.

following requirements in addition to the all criteria

under Subpart B of Part 412 of the regulations:

Form CMS-437A (06/12)

Form Cms-437a - Rehab Unit Criteria Worksheet