Hospital Certificate Of Approval Page 2
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18F-62092 (Rev. 07/08)
Page 2
C. TYPE OF HOSPITAL
General
Critical Access Hospital (CAH)
Special
Long Term Acute Care
Chemical Dependency / Alcohol
Hospital Located Within Another Hospital
Children’s
Maternity
Other
(Specify.)
Rehabilitation
Psychiatric
Orthopedic
Surgical
Name - Fiscal Intermediary
Fiscal Year End Date
D. TYPE OF CERTIFICATION
Applying for:
Medicare (Title XVIII)
Medicare and Medicaid
Medicaid (Title XIX)
State Licensed Only (no TXIX / TXVIII certification)
E. ACCREDITATION STATUS
Non Accredited
Applying for Accreditation with:
JCAHO
AOA
Program JCAHO
Other
Complete the following for CHANGE OF OWNERSHIP applications only.
Accredited by
Accreditation Begin Date
Accreditation End Date
Currently Accredited
JCAHO
AOA
Other
Deemed Begin Date
Deemed End Date
Deemed
F. BED CAPACITY
Indicate the total number of beds requested for those categories that apply.
General Acute Beds
Breakdown
TOTAL Psychiatric Beds
Psychiatric Beds
*PPS Psychiatric Beds
Rehabilitation Beds
*PPS Rehabilitation Beds
TOTAL Rehabilitation Beds
Chemical Dependency / Alcohol Beds
* PPS (Prospective Payment System) excluded psychiatric beds and PPS excluded
rehabilitation beds must have prior approval from the Centers for Medicare and Medicaid
TOTAL BEDS
Services (CMS). If you are adding new PPS excluded psychiatric or rehabilitation beds,
you must include a copy of the CMS approval letter with this application.
Total Number of Acute Care Beds
If Critical Access Hospital (CAH):
Yes
No
Are swing bed services provided?
G. OFFSITE LOCATIONS
Yes
No
Attach additional pages, if necessary.
Name of Off-Site
Type of Provider
Street (Physical) Address
Telephone Number
City
State
Zip Code
Number of Beds
Services Provided
ADVERTISEMENT
0 votes
Related Articles
Related forms
Podiatry Form 4pgy - Certification Of Approved Podiatric Postgraduate Training - New York The State Education Department
Legal
Certificate Of Cancellation Of Limited Partnership - Delaware Division Of Corporations, Certificate Of Cancellation Of Foreign Limited Partnership - Delaware Division Of Corporations
Legal
Related Categories
Parent category: Business