Ambulatory Surgical Center Request For Certification In The Medicare Program {CMS-377}

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0266 AmbulAtory SurgicAl center requeSt for initiAl certificAtion or updAte of certificAtion informAtion in the medicAre progrAm (Please read the following instructions before completing this form) Submission of this form will initiate the process of obtaining a decision as to whether the Conditions for Coverage are met. Assistance in completing the form is available from the State agency. The ASC completes and signs this form for initial certifications and upon request of the State agency for the periodic recertification. Answer all questions as of the current date. Return the original and first two copies to the State agency; retain the last copy for your files. If a return envelope is not provided, the name and address of the State agency may be obtained from the appropriate Regional Office. Please see the following link for additional information: http://www.cms.gov/RegionalOffices/ Detailed instructions are given for questions other than those considered self-explanatory. CMS Certification Number AS1 cmS certification number (ccn): Insert the facility's ten-digit CCN. Leave blank on initial requests for certification. State/county and State region codes: The ASC leaves this blank. item iii: If a service is provided directly by the facility, place a `1' in the appropriate block. If a service is provided under an arrangement with an outside source, place a `2' in the appropriate block. If the service is not provided, leave blank. item iV: Place an `X' in the appropriate blocks representing categories of surgery offered by the ASC. Under "Other," include only broad categories (i.e., not subspecialties). More than one block may be checked. State/County Code AS2 State Region Code AS3 Name of Facility Street Address i. identifying informAtion ii. type of control (Check one box) AS5 City, County, and State Zip Code Telephone No. (Include Area Code) AS4 1. Proprietary 2. Non-Profit 3. Government (Place `1' or `2' in blocks) iii. AncillAry SerViceS iV. SurgicAl SpeciAltieS 1. AS6 Laboratory Dental Endoscopy Ear/Nose/Throat 2. 4. 5. 6. Radiology Ob/Gyn 3. Pharmaceutical Services 7. 8. 9. Pain Plastic/reconstructive Podiatry 2. Date Center Began Providing Services _______________ 10. Other(Specify) 1. 2. AS7 (X appropriate blocks) Ophthalmologic Orthopedic 3. V. fAcility chArActeriSticS 1. Number of Operating Rooms/Procedure Rooms _______________ AS8 AS9 WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS. Signature of Authorized Official (sign in ink) (required only for initial certification) Title Date AS10 According to the Paperwork Reduction of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0266. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimates(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-377 (12/10) American LegalNet, Inc. www.FormsWorkFlow.com