Form Cms-377 - Ambulatory Surgical Center Request For Initial Certification Or Update Of Certification Information In The Medicare Program

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0266

AmbulAtory SurgicAl center requeSt for initiAl certificAtion

or updAte of certificAtion informAtion in the medicAre progrAm

(Please read the following instructions before completing this form)

Submission of this form will initiate the process of obtaining a decision as to whether

cmS certification number (ccn): Insert the facility’s ten-digit CCN. Leave blank on

the Conditions for Coverage are met. Assistance in completing the form is available

initial requests for certification.

from the State agency. The ASC completes and signs this form for initial certifications

State/county and State region codes: The ASC leaves this blank.

and upon request of the State agency for the periodic recertification.

item iii: If a service is provided directly by the facility, place a ‘1’ in the appropriate

Answer all questions as of the current date. Return the original and first two copies

block. If a service is provided under an arrangement with an outside source, place a ‘2’

to the State agency; retain the last copy for your files. If a return envelope is not

in the appropriate block. If the service is not provided, leave blank.

provided, the name and address of the State agency may be obtained from the

item iV: Place an ‘X’ in the appropriate blocks representing categories of surgery

appropriate Regional Office. Please see the following link for additional information:

offered by the ASC. Under “Other,” include only broad categories (i.e., not

subspecialties). More than one block may be checked.

Detailed instructions are given for questions other than those considered

self-explanatory.

CMS Certification Number

State/County Code

State Region Code

AS1

AS2

AS3

Name of Facility

Street Address

i. identifying

informAtion

City, County, and State

Zip Code

Telephone No. (Include Area Code)

AS4

ii. type of control

(Check one box)

Proprietary

Non-Profit

Government

AS5

iii. AncillAry

SerViceS

Laboratory

Radiology

Pharmaceutical Services

(Place ‘1’ or ‘2’ in blocks)

AS6

iV. SurgicAl

Dental

Ob/Gyn

Pain

10.

Other(Specify)

SpeciAltieS

(X appropriate blocks)

Endoscopy

Ophthalmologic

Plastic/reconstructive

Ear/Nose/Throat

Orthopedic

Podiatry

AS7

V. fAcility

1. Number of Operating Rooms/Procedure Rooms _______________

2. Date Center Began Providing Services _______________

chArActeriSticS

AS8

AS9

WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT, MAY BE PROSECUTED UNDER

APPLICABLE FEDERAL AND STATE LAWS.

Signature of Authorized Official (sign in ink) (required only for initial certification)

Title

Date

AS10

According to the Paperwork Reduction 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 0938-0266. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, searching

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 estimates(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-377 (12/10)