Form Cms-1666 - Regional Office Request For Additional Information

ADVERTISEMENT

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
DATE
REGIONAL OFFICE REQUEST FOR
ADDITIONAL INFORMATION OR OTHER ACTION
TO (Name of State Agency or Regional Office)
NAME (Provider or Supplier)
FROM
ADDRESS
ASSOCIATE REGIONAL ADMINISTRATOR
DIVISION OF MEDICAID AND STATE OPERATIONS
ESRD
PORT
INDEPENDENT
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
HOSPITAL
SNF
OPT
HHA
RHC
FACILITY
X-RAY
LABORATORY
Please secure the information or take other action as requested below. Use reverse side for reply. If the file is attached, please return it to the
Regional Office after completion of your development or other action and fasten all new materials inside the folder. If an amended certification is
necessary, please prepare.
REMARKS AND REFERENCES: SEE SOM ________ ROM ___________.
■ ■
■ ■
ATTACHMENTS:
RO PROVIDER/SUPPLIER FILE
OTHER
FORM CMS-1666 (4-80)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2