CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
Form CMS-1539 is the Medicare/Medicaid Certification and Transmittal from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. It records one facility's survey and certification result. The form says Part I is to be completed by the State survey agency and Part II by the CMS Regional Office or Single State Agency.
Part I covers the facility's provider and vendor numbers, the type of action, survey dates, the provider or supplier category, accreditation, compliance status, bed counts, remarks and the surveyor's signature. Part II covers the eligibility determination, civil rights compliance, ownership and solvency statements, agreement dates, termination action and alternative sanctions.
The form is dated 07/84 and the CMS page lists its OMB number as exempt. You can fill it out free in your browser on this page and download the result without an account.
Medicare/Medicaid provider number, State vendor or Medicaid number, facility name and address, type of action, change of ownership date, survey date, provider or supplier category, accreditation status and fiscal year ending date.
Whether the facility is certified as in compliance or not in compliance, with waiver codes, the LTC period of certification, total facility beds, total certified beds, the LTC certified bed breakdown and a yes or no for section 1861(e)(1) or 1861(j)(1).
State survey agency remarks, which the form says should show any LTC cancellation date, the surveyor's signature and the State survey agency approval, each with a date.
Whether the facility is eligible to participate, compliance with the Civil Rights Act, and whether the statement of financial solvency (CMS-2572), the ownership and control interest disclosure statement (CMS 1513) or both apply.
Original date of participation, LTC agreement beginning, ending and extension dates, the termination action code, and alternative sanctions: suspension of admissions and rescind suspension date.
Termination date, intermediary or carrier number, remarks, the date the Regional Office received the CMS-1539, and the determination approval date.
Items are numbered 1 to 32 across the two parts.
In Part I, enter the provider number, State vendor or Medicaid number and the facility's name and address.
Pick the type of action, such as initial survey, recertification, complaint or validation, and enter the survey date, provider or supplier category and accreditation status.
Mark item 10 and any waiver codes, then enter the LTC certification period, bed totals and the LTC certified bed breakdown where they apply.
Enter State survey agency remarks, then the surveyor signature and the State survey agency approval with dates.
The CMS Regional Office or Single State Agency records eligibility, statements, agreement dates, any termination or sanction, and the determination approval date.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The second page of the PDF carries five copy labels: CMS Regional Office, Single State Agency, State Survey Agency (twice) and Courtesy Copy.
The form prints no mailing address. Its parts are marked for the State survey agency and for the CMS Regional Office or Single State Agency.
Item 26 lists voluntary reasons (merger or closure, dissatisfaction with reimbursement, risk of involuntary termination, other reason for withdrawal), involuntary reasons (failure to meet health and safety, failure to meet agreement) and provider status change.
The CMS page lists the OMB number as exempt and its special instructions as N/A. The form prints no separate instructions.
CMS-2567
22 fields, 5 pages
CMS-671
50 fields, 4 pages
CMS-1572
61 fields, 3 pages
CMS-1557
294 fields, 4 pages
CMS-370
10 fields, 2 pages
CMS-801
13 fields, 1 page
The form names who completes each part. Both parts are marked for government agencies.
No tool matches that search.
The form says Part I is to be completed by the State survey agency and Part II by the CMS Regional Office or Single State Agency.
Item 4 lists initial survey, recertification, termination, CHOW, validation, complaint, on site visit, termination of ICF beds and other.
Item 7 has 16 numbered provider and supplier categories, among them hospital, SNF, HHA, lab, X-ray, ESRD, ICF, RHC, CORF, ASC and hospice.
Item 21 refers to the statement of financial solvency (CMS-2572) and the ownership and control interest disclosure statement (CMS 1513), with a code for both.
Item 16, State survey agency remarks, says to show the LTC cancellation date in the remarks if applicable.
The CMS page lists the OMB number as exempt. The form is dated 07/84.