The hospital must be inspected for compliance with the Conditions of Participation as directed by the Centers for Medicare and Medicaid Services. A facility seeking initial licensure and certification will receive two (2) inspections; one licensure survey before operation begins followed by a certification survey after the facility is fully operational. Psychiatric facilities require an additional certification of the Medicare special Conditions of Participation for Psychiatric Hospitals.
Participation in the Medicare/Medicaid program(s) will depend upon an effective date recommended by the Agency for Health Care Administration. Federal regulations permit this date to be the date of initial certification if all federal requirements are met or the date an acceptable plan of correction or waiver request is received.
|Medicare Administrative Contractor Choice Form [190KB, PDF]||Identifies the facility's intermediary and cost reporting fiscal year end.|
|Health Insurance Benefit Agreement Form (Form CMS -1561) [PDF]||Agreement to conform to the provisions of section of 1866 of the Social Security Act and applicable provisions in 42 CFR.|
|Hospital/CAH Database Worksheet [249KB, PDF]||Information will be collected on-site if an inspection is required. For a change of ownership, data must be supplied to the licensure unit.|
|Medicare Certification Civil Rights Information Request Form [PDF]||Checklist of required information. Appropriate facility policies and brochures must be attached.|
|Assurance of Compliance (Form HHS - 690) [PDF]||Required form to be submitted with the above civil rights form.|
|Technical Assistance Information and Civil Rights Sample Policies and Procedures||Technical assistance provided by the Office of Civil Rights. This information includes examples of the information to be submitted with the above Medicare Certification Civil Rights Information Request Form.|
|Note: Providers now have the option of answering all questions and submitting the civil rights clearance package on line.|
Additional Civil Rights Information and Forms