Form Cms-838 Medicare Credit Balance Report Certification Page

ADVERTISEMENT

FORM CMS-838
Medicare Credit Balance Report
Certification Page
MEDICARE CREDIT BALANCE REPORT CERTIFICATION
The Medicare Credit Balance Report is required under the authority of Sections 1815(a), 1833(e),
1886(a)(1)(C) and related provisions of the Social Security Act. Failure to submit this report may result in
a suspension of payments under the Medicare program and may affect your eligibility to participate in the
Medicare program.
ANYONE WHO MISREPRESENTS, FALSIFIES, CONCEALS OR OMITS ANY
ESSENTIAL INFORMATION MAY BE SUBJECT TO FINE, IMPRISONMENT OR
CIVIL MONEY PENALTIES UNDER APPLICABLE FEDERAL LAWS.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER (S)
I HEREBY CERTIFY that I have read the above statements and that I have examined the accompanying
credit balance report prepared
by
__________________________________
_____________________________________
Provider Name
Provider 6-Digit Number
for the calendar quarter ended
____ and that it is a true, correct, and complete statement
prepared from the books and records of the provider in accordance with applicable Federal laws,
regulations and instructions.
(Sign)
Officer or Administrator of Provider
(Print)
Name and Title
(Print)
Date
CHECK ONE:
[ ]Qualify as a Low Utilization Provider.
[ ]The Credit Balance Report Detail Page(s) is attached.
[ ]There are no Medicare credit balances to report for this quarter. (No Detail Page(s) attached.)
Contact Person
Telephone Number
FORM APPROVED
OMB NO. 0938-0600 (10/2002)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go