Form Cms-729 - Data Collection Medical Staff Coverage

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0378

DATA COLLECTION MEDICAL STAFF COVERAGE (certified beds only)

Hospital

Date

FULL-TIME (FTEs)

PART-TIME (PTEs)

COMMENTS

1. Medical Staff Coverage

Board Certified MDs (Psy.)

Fully Trained MDs (Psy.)

Board Certified MDs (Neuro.)

Fully Trained MDs (Neuro.)

Internist (Specialty)

Family Practice (Boarded)

Physicians with Limited Licensure

General Practice

Physician Assistants

2. Other

(specify, for example Consultants

who spend time at the hospital)

3. If residents are utilized for work assignments, specify FTEs and assignments, as well as numbers and the amount of

hospital staff time used for supervision.

4. Specify how On-Call medical coverage and assignments are handled (nights, weekends, and holidays)

5. Vacancies

6. On leave

Signature of CMS Surveyor

Signature of Clinical Director

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information

collection is 0938-0378. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data

needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports

Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

FORM CMS-729 (09/94)

(OPTIONAL)