Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 5/17/2023
Medicare-Medicaid Certification And Transmittal {CMS-1539}
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Description
CMS-1539 - MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. This form is divided into two parts. Part 1 is to be completed by the State Survey Agency, and Part 2 is to be completed by the CMS Regional Office or Single State Agency. The form collects information related to the facility's Medicare/Medicaid provider number, facility name and address, type of action (such as initial survey, recertification, termination), effective date for change of ownership, provider/supplier category, accreditation status, compliance with program requirements, facility beds, certified beds, LTC certification bed breakdown, and remarks from the State Survey Agency. Part 2 includes information about the determination of eligibility, compliance with the Civil Rights Act, financial solvency statement, ownership and control interest disclosure statement, participation dates, termination action, alternative sanctions, intermediary/carrier number, and additional remarks. www.FormsWorkflow.com
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