Form Cms-339 - Provider Cost Report Reimbursement Questionnaire
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
2504-06
FORM CMS-339
1102.3 (Cont.)
EXHIBIT 1
FORM APPROVED
OMB NO. 0938-0301
This questionnaire is required under the authority of sections 1815(a) and 1833(e) of the Social
Security Act. Failure to submit this questionnaire will result in suspension of Medicare payments.
To the degree that the information in CMS-339: 1) constitutes commercial or financial information
which is confidential, and/or 2) is of a highly sensitive personal nature, the information will be
protected from release under the Freedom of Information Act.
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 0938-0301. The time required to complete this information collection is
estimated to average 17 hours and 20 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 comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
(You MUST USE Instructions For Completing This Form
Located In PRM-II, §§1100ff.)
Provider Name:
Provider Number(s):
______________________________________________________________________________
Filed with Form CMS-
Period:
/ /1728 / /2552 / /2088 / /2540 / / 2540S
From
____________________
/ /
(Other - Specify)
To ____________________
INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION
CONTAINED IN THIS QUESTIONNAIRE MAY BE PUNISHABLE BY FINE AND/OR
IMPRISONMENT UNDER FEDERAL LAW
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above statement and that I have examined the
accompanying information prepared by _____________________________________________
(Provider name(s) and number(s)) for the cost report period beginning _____________________
and ending ________________, and that to the best of my knowledge and belief, it is a true, correct
and complete statement prepared from the books and records of the provider(s) in accordance with
applicable instructions, except as noted.
(Signed)
Officer or Administrator of Provider(s)
Date
Title
Name and Telephone Number of Person to Contact for More Information
Rev. 6
11-15
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 3076 - Supplemental Cost Report Schedule B For Intermediate Care Facilityfor The Developmentallydisabled (habilitative Or Nursing) Adult Day Services And Related Transportation Cost
Legal
Related Categories
Parent category: Medical