The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Many CMS program related forms are available in Portable Document Format (pdf). Hard copy forms may be available from Intermediaries, Carriers, State Agencies, local Social Security Offices or End Stage Renal Disease (See State Operations Manual §2764.) *Hospital Survey Report Crucial Data Extract CMS-1537E *Medicare/Medicaid Hospital Swing-Bed Survey Report CMS-1537C . Initial Certification (Attestation) for Rehabilitation or Psychiatric Units *Home Health Agency Survey and Deficiencies Report CMS-1572a,b . Original Health Insurance Benefit OMB Control No: 0938-0355 ICR Reference No: 202102-0938-001 Status: Received in OIRA Previous ICR Reference No: 201706-0938-001 Agency/Subagency: HHS/CMS Agency Tracking No: 20516 Title: (CMS-1572) Home Health Agency Survey and Deficiencies Report and Supporting Regulations Type of Information Collection: Reinstatement with change of a previously approved collection 3. Complete all areas of the CMS-1572 (a) (b) (one sheet) except the following areas: #7, #8, #12, #21, and #23. Under 19, make sure that the FTE hours are indicated as .00, .25, .50,.75, etc. Make sure to include contracted staff. 4. Complete the MN-1513 - Ownership Information 5. Total number of unduplicated admissions from all payor sources CMS 1572A Form: HHA SURVEY & DEFICIENCIES REPORT: $8.99. CMS 1592 Form: SMI PREMIUM ACCOUNTING Form: $8.99. CMS 1666 Form: REGIONAL OFFICE REQUEST FOR ADDITIONAL Information: Certificate of Medical Necessity-Manual Wheelchairs, DMERC 02.03B: $8.99. CMS 845 Form: Certificate of Medical Necessity-Continuous Positive Airway Pressure: $8.99. 0990-0243, HHS-690, CMS-1561, CMS-1572A, BHCS-HFD-150, BHCS-HFD-803 (branch site application) • FI/MAC reviews application and makes recommendation to instructions for timely discharge or referral, and any other appropriate items. §484.55(c)/G0337 Standard: Drug Regimen Review: The comprehensive assessment must include a review of One (1) signed original HHA Survey and Deficiencies Report (CMS-1572A - Only complete numbers 1-10 and 12-20.) Contact Accrediting Organization (AO) to schedule survey (initial only) For address/location changes: Complete Provider Enrollment Application and submit to MAC/FI within 90 days of the move CMS takes approximately 8 weeks to determine whether the facility meets the requirements to participate in the Medicare program. CMS requires that the application documents be signed no more than 6 months prior to CMS' review. If the process takes more than 6 months, CMS may require the facility to submit updated forms. Keep to these simple actions to get Cms 1572 prepared for submitting: Get the document you will need in the library of legal templates. Open the template in the online editor. Look through the instructions to find out which details you have to give. Select the fillable fields and include the