Form Cms-838 - Medicare Credit Balance Reporting Requirements

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DEP
DEPAR
ARTMENT
TMENT OF HEAL
OF HEALTH
TH AND HUMAN SER
AND HUMAN SERVICES
VICES
Form Approved
Form Approved
CENTERS FOR MEDICARE & MEDICAID SER
CENTERS FOR MEDICARE & MEDICAID SERVICES
VICES
OMB No. 0938-0600
OMB No. 0938-0600
MEDICARE CREDIT BALANCE REPORT
CERTIFICATION PAGE
The Medicare Credit Balance Report is required under the authority of sections 1815(a), 1833(e),
1886(a)(1)(C) and related provisions of the Social Security Act. Failure to submit this report may result in a
suspension of payments under the Medicare program and may affect your eligibility to participate in the
Medicare program.
ANYONE WHO MISREPRESENTS, FALSIFIES, CONCEALS OR OMITS ANY ESSENTIAL
INFORMATION MAY BE SUBJECT TO FINE, IMPRISONMENT OR CIVIL MONEY PENALTIES
UNDER APPLICABLE FEDERAL LAWS.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER
I HEREBY CERTIFY that I have read the above statements and that I have examined the accompanying credit
balance report prepared by
___________________________________________________
_________________________________
Provider Name
Provider 6-Digit Number
for the calendar quarter ended_____________________and that it is a true, correct, and complete statement
prepared from the books and records of the provider in accordance with applicable Federal laws, regulations
and instructions.
(Sign) ____________________________________________
Officer or Administrator of Provider
(Print) ____________________________________________
Name and Title
(Print) ____________________________________________
Date
CHECK ONE:
❑
Qualify as a Low Utilization Provider.
❑
The Credit Balance Report Detail Page(s) is attached.
❑
There are no Medicare credit balances to report for this quarter. (No Detail Page(s) attached.)
___________________________________________________
_________________________________
Contact Person
Telephone Number
Form CMS-838 (10/03)
Form CMS-838 (10/03)
INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT -
PROVIDER INSTRUCTIONS, FORM CMS-838

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