Responsibilites Of Medicare Participating Hospitals In Emergency Cases Investigation {CMS-1541B}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS & CRITICAL ACCESS HOSPITALS (CAHS) IN EMERGENCY CASES INVESTIGATION REPORT 1. Name of Facility 2. Street Address 3. City and/or County 4. State 5. ZIP Code 6. CMS Certification No. 7. Name of CEO and CEO email address 8. Telephone Number 9. State/Region Code 10. State/Country Code 11. Dates of Survey _____ / _____ / __________ to _____ / _____ / __________ 12. Medicare No. of Certified Beds 13. ACTS Complaint Intake No. 14. Type of Survey Complaint Revisit 15. SA Recommendation: In Compliance - No Further Action Recommend Termination (23 Day) Recommend Termination (90 Day) In Compliance but previously Out of Compliance (choose for self-reported allegations only) Possible Discrimination - refer to OCR For Complaint Survey: I certify that I have reviewed the requirements of 42 CFR 489.24 and the related provisions of 42 CFR 489.20 and, unless indicated otherwise on the related Form CMS 2567, the facility was found to be in compliance with the regulations. Signature Title Date Signature Title Date For Revisit: For the purpose of a revisit, I certify that I have reviewed the facility's current compliance with the requirements for which they were not in compliance during the survey on and unless indicated otherwise on the related Form CMS 2567, the facility was found to be in compliance with those requirements. Signature Title Date Signature Title Date Form CMS-1541B (Exempt) American LegalNet, Inc. www.FormsWorkFlow.com