MEMORANDUM Texas Department of Human Services
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- Robert Kelly
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1 MEMORANDUM Texas Department of Human Services TO: FROM: Long Term Care-Regulatory Regional Directors and State Office Managers Jeanoyce Wilson, Unit Manager Long Term Care-Regulatory Policy Unit State Office MC W-519 SUBJECT: Regional Survey and Certification (RS&C) Letter No (This RS&C letter supercedes RS&C letter and revises HSQ letter 88-01) DATE: May 12, 2003 The attached Centers for Medicare and Medicaid Services (CMS), Regional Survey and Certification (RS&C) Letter is being provided to you for information purposes and should be shared with all professional staff. RS&C Letter No Procedural Changes for ASC s, CHMC s, CORF s, ESRD s, Hospitals and OPT/SP Provider/Suppliers If you have any questions about this subject, please contact the Texas Department of Health (TDH), Health Facility Licensing and Compliance Division at (512) [signature on file] Jeanoyce Wilson JW:bbm Attachment c: Evelyn Delgado, E-340 Paul Leche, W-615 Merrie Duflot, W-404 Regional Administrators
2 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Division of Survey and Certification, Region VI 1301 Young Street, Room 827 Dallas, Texas Phone (214) Fax (214) April 16, 2003 Regional Survey and Certification Letter No To: All State Survey Agencies (Action) All Title XIX Single State Agencies (Information) Subject: Procedural Changes for ASCs, CMHCs, CORFs, ESRDs, Hospitals, and OPT/SP provider/suppliers This Regional Survey and Certification (RS & C) letter supercedes RS & C letter and revises HSQ letter There are some inconsistencies in the way our State survey agencies are submitting provider/supplier certification packets to the regional office (RO) for approval/denial actions. The State agency (SA) should ensure that the following sections on the C & T are completed for the providers listed above: 1. (L24) Original Date of Participation (On CHOWs Only) 2. (L31) Intermediary/Carrier number 3. Number 16 - State Survey Remarks. In this section annotate appropriate detailed information, such as change of name and/or address, change in bed sizes, changes in services, addition or deletion of stations (ESRD), extensions (OPT/SP) and effective date of changes. On initial certification activities, list the approved services, SA recommendation for approval or denial of certification and effective date. Effective immediately (for providers/suppliers listed above only): The following notification and certification activities for ESRDs, OPT/SP, CORFs, CMHCs, Hospitals & ASCs will be transferred from the SA to the Regional Office (RO). The HCFA-1539 will be sent by the SA to the RO for (a) name changes, (b) address changes, (c) changes in services, (d) addition or deletion of stations (ESRD), (e) extension approvals (OPT/SP).
3 The RO will return copies of the approved /denied HCFA-1539 to the SA and intermediaries to update the computer database (Oscar/Odie, Aspen, etc.). *Please remember the HCFA-1540 is obsolete and should not be used. ESRD suppliers do not need to complete Health Insurance Benefit Agreements (HCFA-1561). Enclosed is a list of instructions for completing SA packets that are sent to the RO by provider type. If you have any questions regarding OPT/SP, CORFs, or CMHCs contact Connie Jones at (214) ; ESRDs, Rachel McCarty at (214) ; and Hospitals or ASCs, Colleen Sanders at (214) , Hospital Complaints Juanita Cortez at (214) Sincerely, Enclosures- ASC Workflow (Attachment 1) CMHC Workflow (Attachment 2) CORF Workflow (Attachment 3) ESRD Workflow (Attachment 4) HOSPITAL Workflow (Attachment 5) OPT Workflow (Attachment 6) *ESRD Suppliers only Molly Crawshaw Survey and Certification Operations Branch Division of Survey and Certification
4 Initials Unaccredited (State) Ambulatory Surgical Center (Attachment 1) Ambulatory Surgical Center Survey Report Ambulatory Surgical Center Request to Certification Health LSC Health Insurance Benefit Agreement (3 signed copies) CMS-378 CMS-377 CMS-370 Initial AAAHC\JCAHO\AAAASF Accreditation Ambulatory Surgical Center Survey Report Ambulatory Surgical Center Request to Certification Health Insurance Benefit Agreement (3 signed copies) Official Accreditation Decision Report CMS-378 CMS-377 CMS-370 Change of Ownership (CHOW s) Ambulatory Surgical Center Request to Certification Health Insurance Benefit Agreement (3 signed copies) Legal Documentation of Sales/Purchase/Lease CMS-377 CMS-370 Denial Same forms as an initial. Validation / Complaints Medicare/Medicare/Complaint Form (Complaint) Ambulatory Surgical Center Request to Certification Ownership and Control Interest Disclosure Statement Health LSC All letter sent provider and/or complainant (Both) Crucial Data Extract-ASC Crucial Data Extract-LSC Fire Safety Survey Report Narrative Report (complaint) CMS-562 CMS-377 CMS-1513 CMS-378E CMS-2786E CMS-2786H Follow-up reports on ASC s under SA monitoring should contain the following:
5 Certification and Transmittal (Item 11 completed with either box 2 or box 4 checked) Post-Certification Revisit Report CMS-l539 B For actions not listed follow the same procedures used by the hospital. The requested forms will be different. Please call Colleen Sanders at for guidance and assistant. If not available call the main number at
6 Community Mental Health Centers (Attachment 2) REGIONAL OFFICE DOCUMENTS Send the following forms to the CMS Regional Office: Initial Certification & FI Approval letter (Exhibit 5 in SOM) CMHC Crucial Data Extract (CDE) (Exhibit 131in SOM) CMHC Provider Agreement (Exhibit 276 in SOM) 3 signed originals Attestation Statement (Exhibit 275 in SOM) Change of Ownerships (CHOWs) CMHC Crucial Data Extract (CDE) (Exhibit 131in SOM) CMHC Provider Agreement (Exhibit 276 in SOM) 3 copies Legal Documentation of Sale Involuntary Terminations Any other supporting documentation Voluntary Terminations/Cessation of Business Proof of the reason for voluntary termination or withdrawal Copy of newspaper notice (if applicable) Complaints Medicare/Medicaid/CLIA Complaint Form Narrative Report CMS-2572 CMS-562 Name Change/Address Change Any supporting documentation that shows changes Note: CMHCs should have prior RO approval before relocation to ensure new location remains in the same community.
7 Comprehensive Outpatient Rehabilitation Facilities (Attachment 3) REGIONAL OFFICE DOCUMENTS Send the following forms to the CMS Regional Office: Initial Certification & FI Approval CMS 359 Health Benefit Agreement ( 07/01 version) CMS CORF Survey Report CMS CMS 670 Statement of Fiscal Year End Change of Ownerships (CHOWs) & FI Approval Health Insurance Benefit Agreement ( 3 copies) CMS Legal Documentation of Sale Statement of Fiscal Year End Initial Denials CMS Health Insurance Benefit Agreement ( 3 signed originals) (07/01version) CORF Survey Report CMS CMS 670 Statement of Fiscal Year End Involuntary Terminations Any other supporting documentation
8 Voluntary Terminations/Cessation of Business Proof of the reason for voluntary termination or withdrawal Copy of newspaper notice (if applicable) Complaints Medicare/Medicaid Certification and Transmittal (C & T) CMS Medicare/Medicaid/CLIA Complaint Form CMS 562 Narrative Report Further instructions will be given with the implementation of the ACTS Name Change/Address Change & FI Approval Any supporting documentation that shows changes Addition/Deletion of Services Medicaid Certification and Transmittal (C&T) CMS 359 CORF Survey Report CMS CMS 670 Any supporting documentation that shows changes
9 END STAGE RENAL DISEASE (Attachment 4) REGIONAL OFFICE DOCUMENTS Send the following forms to the CMS Regional Office: Initial Certification (include intermediary approval letter) ESRD Application/Notification and Survey and Certification Report Expression of Intermediary Preference Change of Ownerships (CHOWs) (include intermediary approval letter) ESRD Application/Notification and Survey and Certification Report Legal Documentation of Sale Expression of Intermediary Preference Initial Denials (include intermediary approval letter) Involuntary Terminations Any other supporting documentation Voluntary Terminations/Cessation of Business Proof of the reason for voluntary termination or withdrawal Copy of newspaper notice (if applicable) Complaints (Substantiated Only) Medicare/Medicaid/CLIA Complaint Form Narrative Report Name Change/Address Change/Addition or Deletion of Stations or Services (Name & Address Change only) ESRD Application/Notification and Survey and Certification Report Any supporting documentation that shows changes CMS-3427 CMS-3427 CMS-562 CMS-3427
10 Hospitals (Attachment 5) Please contact the following RO staff according your action: Colleen Sanders Charlene Belfrey Juanita Cortez Dodjie Guioa Dorsey Sadongei David Wright Initials, chows, validation, etc. (see list below) PPS Units, LTC & CAH Complaints, JCAHO, Termination EMTALA in Texas EMTALA in Oklahoma and New Mexico EMTALA in Arkansas and Louisiana Please forward the following hospital forms according to the action: Initial Certifications Acute JCAHO/AOA Accredited Hospitals - Statement of Intermediary Preference Health Insurance Benefit Agreement (3 signed copies) Official Accreditation Decision Report CMS-2572 Acute Unaccredited Hospital (State) Health LSC Statement of Intermediary Preference CMS 2572 Health Insurance Benefit Agreement (3 signed copies) PPS HOSPITALS Psychiatric - Accredited JCAHO/AOA Hospitals - Health Health Insurance Benefit Agreement (3 signed originals) Statement of Intermediary Preference CMS-2572
11 Official Accreditation Decision Report Psychiatric - Unaccredited (State) Hospitals - Health LSC Psychiatric Hospital Survey Report Health Insurance Benefit Agreement (3signed originals) Statement of Intermediary Preference CMS-1537A CMS-2572 An initial packet for a psychiatric hospital either certified by a national accrediting organization or by the State must include the two Special Conditions. These conditions must be surveyed by qualified psychiatric personnel. If the state does not have a qualified individual arrangements should be made with the regional office of CMS before scheduling the initial survey so that arrangement can be made with Central Office psychiatric consultants. Rehabilitation Accredited JCAHO/AOA Hospitals Health Insurance Benefit Agreement (signed originals) Statement of Intermediary Preference CMS-2572 A hospital would have to provide to the State a written certification that inpatient population it intends to serve meets the requirements of (b)(2). Rehabilitation Unaccredited (State) Hospitals - Health Health Insurance Benefit Agreement (signed originals) Statement of Intermediary Preference Rehabilitation Hospital Criteria Worksheet CMS-2572 CMS-437B Children s Hospital Accredited/Unaccredited Paperwork is the same as an acute hospital Accredited/Unaccredited. The intermediary will verify the age criterion to indicate that majorities of the hospital s inpatients are individuals under the age of 18. 2
12 Swing-Beds Request for Approval as a Hospital Provider of Extended Care Services Hospital Survey Report Crucial Data Extract Medicare/Medicaid Hospital Swing-Bed Survey Report CMS-605 CMS-1537E CMS-1537C Validations/Complaints Medicare/Medicare/Complaint Form (Complaint) Ownership and Control Interest Disclosure Statement Crucial Data Extract - Health (if applicable) Crucial Data Extract - Life Safety Code (if applicable) - Health (if applicable) - LSC (if applicable) All letters sent to provider and/or complainant (Both) Narrative Report (Complaints) Follow-up reports on hospitals under SA monitoring should contain the following: Certification and Transmittal (Item 11 completed with either box 2 or box 4 checked) Post-Certification Revisit Report CMS-562 CMS-1513 CMS-1537E CMS-2786E CMS-l539 B Recertification-Accredited JCAHO/AOA Hospital- Short Term Ownership and Control Interest Disclosure Statement CMS-1513 Change of Ownership (CHOW s)/merger Statement of Intermediary Preference Health Insurance Benefit Agreement (3 signed copies) Legal Documentation of Sales/Purchase/Lease MS-855 CMS
13 Voluntary Termination/Cessation of Business Letter from the facility that is voluntary termination or withdrawal Copy of newspaper notice (if applicable) Involuntary Termination Refer to RSC-Letter No on required forms. Denial Same forms as an initial. Name Change/Address Change/Addition or Deletion of Stations or Services Any supporting documentation about changes Emergency Services for a non-participating hospital Any supporting documentation of service (By Facility) The SA annotates at the top of form, Emergency Hospital Services Only For areas not listed, please call CMS for guidance at
14 Outpatient Physical Therapy (OPT) (Attachment 6) REGIONAL OFFICE DOCUMENTS Send the following forms to the CMS Regional Office: Initial Certification & FI Approval CMS OPT/SP Survey Report CMS Health Insurance Benefit Agreement (3 signed originals) (07/01 version) CMS 1561 CMS 670 Statement of Fiscal Year End List of Personnel and Job Titles Copy of Provider s Social/Vocational Adjustment Services Screening Form (If applicable) Change of Ownerships (CHOWs) & FI Approval Health Insurance Benefit Agreement ( 07/01 version) CMS Statement of Fiscal Year End Legal Documentation of Sale Extension Unit Request & FI Approval ( 1539 must note the services provided at the extension location) Requesting Identification of Extension Units CMS-381 Initial Denials CMS OPT/SP Survey Report CMS Health Insurance Benefit Agreement (3 signed originals) (07/01 version) CMS 1561 CMS 670
15 Statement of Fiscal Year End Involuntary Terminations Any other supporting documentation Voluntary Terminations/Cessation of Business Proof of the reason for voluntary termination or withdrawal Copy of newspaper notice (if applicable) Extension Closure & FI Approval Complaints Medicare/Medicaid Certification and Transmittal (C & T) CMS 1539 Medicare/Medicaid/CLIA Complaint Form CMS 562 Statement of Deficiencies and Plan o Correction CMS Narrative Report Further instructions will be given with the implementation of the new ACTS Name Change/Address Change & FI Approval Any supporting documentation that shows changes Addition or Deletion of Services Any supporting documentation that verifies changes CMS OPT/SP Survey Report CMS CMS 670 Note: Form 381 must be updated annually by OPT providers and a SA report must be submitted to the RO.
Kathleen Lucas, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: IXBL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Mary Heim, HPR-Social Work Specialist 09/03/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: NKFZ PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Jessica Sellner, HFE, NEII 11/23/2011 Colleen B. Leach, Program Specialist 01/13/2012
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: DDG9 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00351
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: M4JX PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Brenda Fischer, Unit Supervisor 09/13/2012 Colleen B. Leach, Program Specialist 09/18/2012
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: LNUX PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 2FT5 Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00858
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 2LL3 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Michelle McFarland, HFE NEII
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: PH3B Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: X60T Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00712
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: H0RJ PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Patricia Halverson, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: VWX6 Facility ID:
Gary Nederhoff, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 94CQ Facility ID:
James Anderson, State Fire Marshall
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 2HL7 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 8MXL Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 8L7Q Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00903
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: RHTV PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00940
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: FU8X PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00719
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 93NN PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 0D7L Facility ID:
Patricia Halverson, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES 1. MEDICARE/MEDICAID PROVIDER NO. (L1) 2.STATE VENDOR OR MEDICAID NO. (L2) 5. EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 6. DATE OF SURVEY (L34) 8. ACCREDITATION STATUS:
07/23/ /21/2013 (L20)
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 04CB PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00861
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 33K1 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00166
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 6PJU PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
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MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00598
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: L7X6 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Lou Anne Page, HFE NE II
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: Z6PT PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
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MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: GR6J Facility ID:
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