Form Cms-417 - Hospice Request For Certification In The Medicare Program

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No.0938-0313

CENTERS FOR MEDICARE & MEDICAID SERVICES

INSTRUCTIONS FOR COMPLETING HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM

STATEMENT CONCERNING INFORMATION COLLECTION REQUIREMENTS AND USES:

This form is required to obtain or retain Medicare benefits. It serves two purposes. First, it provides basic information about the Hospice which is necessary for the State to

properly schedule a survey. Second, it provides a data-base necessary for responding to questions frequently asked by Congress, Federal agencies, and interested members of

the public.

Submission of this form will initiate the process of obtaining a decision as to whether the Conditions are met.

Answer all questions as of the current date. Complete and return this form to your State Agency (found at

https://

Certification/SurveyCertificationGenInfo/downloads/state_agency_contacts.pdf), and retain a copy for your files.

Detailed instructions are given for questions other than those considered self-explanatory.

Item I:

•

Request to establish eligibility in—current Hospice Benefits are available only through the Medicare program.

•

Medicare certification number:

Insert the facility’s six digit Medicare Certification Number. Leave blank on initial requests for certification.

•

State/County and State/Region Codes:

Leave blank. The Centers for Medicare & Medicaid Services Regional Office will complete.

•

Related certification number:

If Hospice is affiliated with any other type Medicare provider, insert the related facility’s six digit Medicare Certification Number.

Item IV:

•

If a service is provided directly by the facility place a “1” the appropriate block.

•

If a service is provided through an outside source (i.e., by contract/arrangement), place a “2” in the appropriate block.

•

If a service is provided both directly and through arrangement, place a “3” in the appropriate box.

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 0938-0313. The time required to complete this information collection is estimated to average 15 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.