Form Cms-673 - Extended/partial Extended Survey Worksheet
Download a blank fillable Form Cms-673 - Extended/partial Extended Survey Worksheet in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-673 - Extended/partial Extended Survey Worksheet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2■
■
■
■
■
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
EXTENDED/PARTIAL EXTENDED SURVEY WORKSHEET
FACILITY
STANDARD OR ABBREVIATED SURVEY DATES
_____/_____/_____ to _____/_____/_____
Mo
Day
Yr
Mo
Day
Yr
PROVIDER NO.
EXTENDED/PARTIAL EXTENDED SURVEY DATES
_____/_____/_____ to _____/_____/_____
Mo
Day
Yr
Mo
Day
Yr
■ Extended Survey: Substandard care determined during Standard Survey resulting in Extended Survey.
■ Partial Extended Survey: Substandard care determined during Abbreviated Survey resulting in Partial Extended Survey.
Check all requirements not met that resulted in the Extended or Partial Extended Survey.
■
■
■
483.13
483.15
483.25
Document observations from extended/partial extended survey
Tag/Concern
(continued on back)
Form CMS-673 (07/95)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical