Form Cms-724 - Medicare/medicaid Psychiatric Hospital Survey Data

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0378
MEDICARE/MEDICAID PSYCHIATRIC HOSPITAL SURVEY DATA
SECTION I: to be completed by hospital
Name of Hospital
Street Address
City or County
State
ZIP Code
B4
B1
B2
B3
B5
Hospital Provider Number
Total Number of Beds
Total Number of Certified Beds
Other Data — Does the hospital operate a forensic unit?
■
■
Yes
No
B6
B7
B8
B9
For the past year: A. Total number of admissions to certified areas
B. Age Range of Patients
from (month)__________
(year)___________
B10
B11
C. Medicare/Medicaid Billings
D. Other Data — Does the hospital operate a separate MEDICAID ONLY-Residential
Treatment Program for Psychiatric patients under the age of 22?
Billed
Collected
■
■
Yes
No
MEDICARE/Part A
MEDICARE/Part B
MEDICAID
B12
13. Current Hospital Statistics (on days of survey) [certified beds only]
Name of Ward
Bed Capacity
Patient Census
Total Patient Census
B13
Page 1
Form CMS-724 (09/94)

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