Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 1/29/2025
Health Insurance Benefits Agreement {CMS-370}
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Description
CMS-370 - HEALTH INSURANCE BENEFITS AGREEMENT. This form is a contract between an Ambulatory Surgical Center (ASC) and the Centers for Medicare & Medicaid Services (CMS) under Section 1832(a)(2)(F) of the Social Security Act. This agreement establishes the ASC’s eligibility for Medicare payments and outlines the ASC’s obligations, including maintaining compliance with federal regulations, not charging Medicare beneficiaries for covered services, promptly refunding incorrect payments, providing information for payment rate determinations, accepting assignment for facility services, and complying with quality improvement reviews. The agreement becomes effective upon acceptance by the Secretary of Health and Human Services and remains in effect unless terminated. It also continues in the event of a transfer of ownership. False statements or fraudulent information in connection with this agreement may result in fines or imprisonment under 18 U.S.C. § 1001. www.FormsWorkflow.com
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