Items 1 to 5: facility and address
Name of facility, street address, city and/or county, state and ZIP code.
CMS-1541B
RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT
- Agency
- CMS
- Revision
- 2014-09-01
- Fillable fields
- 38
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-1541B: Hospital and CAH Responsibilities in Emergency Cases Investigation Report
Form CMS-1541B is the Responsibilities of Medicare Participating Hospitals & Critical Access Hospitals (CAHs) in Emergency Cases Investigation Report, from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. The CMS forms page lists it as Responsibilities of Medicare Participating Hospitals in Emergency Cases Investigation Report, with a revision date of 2014-09-01 and an OMB number of exempt. The form itself is marked Form CMS-1541B (Exempt).
It is a one-page report. Items 1 to 14 identify the facility, its CMS Certification Number, CEO, number of Medicare certified beds, ACTS complaint intake number, the dates of survey and the type of survey, complaint or revisit. Item 15 is the SA Recommendation, with five boxes.
Two certification blocks follow, one for a complaint survey and one for a revisit, each with two signature lines. Both refer to the related Form CMS-2567. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-1541B
Items 6 to 10: identifiers and contact
CMS Certification No., name of the CEO and CEO email address, telephone number, State/Region Code and State/Country Code.
Items 11 to 14: the survey
Dates of survey from and to, Medicare No. of Certified Beds, ACTS Complaint Intake No., and type of survey: Complaint or Revisit.
Item 15: SA Recommendation
In Compliance - No Further Action; In Compliance but previously Out of Compliance, which the form says to choose for self-reported allegations only; Recommend Termination (23 Day); Recommend Termination (90 Day); and Possible Discrimination - refer to OCR.
Complaint survey certification
A statement that the requirements of 42 CFR 489.24 and related provisions of 42 CFR 489.20 were reviewed and, unless indicated otherwise on the related Form CMS-2567, the facility was found in compliance. Two signature, title and date lines.
Revisit certification
A statement for a revisit with a blank for the date of the earlier survey, again referring to the related Form CMS-2567. Two signature, title and date lines.
The form is numbered items 1 to 15 plus two certification blocks.
How to fill out Form CMS-1541B
- 1
Enter the facility
Fill in items 1 to 5: the facility name, street address, city and/or county, state and ZIP code.
- 2
Add identifiers and contacts
Fill in items 6 to 10: CMS Certification No., the CEO's name and email address, telephone number and the two codes.
- 3
Describe the survey
Enter the dates of survey, the number of Medicare certified beds and the ACTS complaint intake number, then check Complaint or Revisit in item 14.
- 4
Mark the SA recommendation
Check a box in item 15. The form says the In Compliance but previously Out of Compliance box is for self-reported allegations only.
- 5
Sign the matching certification
Use the complaint survey block or the revisit block. Each has two lines for a signature, title and date. The revisit block also asks for the date of the earlier survey.
The form prints no instructions. These steps follow its items in order.
Why fill Form CMS-1541B on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
What the form says about filing and related forms
Where it goes
The form does not print a mailing address or say where it is sent.
Related Form CMS-2567
Both certification blocks say the facility was found in compliance unless indicated otherwise on the related Form CMS-2567.
Regulations named
The complaint survey certification names 42 CFR 489.24 and the related provisions of 42 CFR 489.20.
OMB status and revision
The form is marked Form CMS-1541B (Exempt). The CMS page lists the O.M.B. number as EXEMPT and the revision date as 2014-09-01.
Related forms
CMS-2567
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
22 fields, 5 pages
CMS-807
Surveyor Notes Worksheet
11 fields, 2 pages
CMS-801
Offsite Survey Prep Worksheet
13 fields, 1 page
CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
51 fields, 2 pages
CMS-2802E
REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY
35 fields, 1 page
CMS-10455
Report of a Hospital Death Associated with Restraint or Seclusion
38 fields, 1 page
Who uses Form CMS-1541B?
The form does not spell out who fills it in. Its items point to the parties below.
Official sources and the blank
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Questions about Form CMS-1541B
What is Form CMS-1541B?
It is the Responsibilities of Medicare Participating Hospitals & Critical Access Hospitals (CAHs) in Emergency Cases Investigation Report from CMS, a one-page report on a complaint survey or revisit.
Which facilities does Form CMS-1541B cover?
The form's title names Medicare participating hospitals and critical access hospitals (CAHs). The CMS forms page title names Medicare participating hospitals.
What recommendations can item 15 record?
In Compliance - No Further Action, In Compliance but previously Out of Compliance (self-reported allegations only), Recommend Termination (23 Day), Recommend Termination (90 Day), and Possible Discrimination - refer to OCR.
How does Form CMS-1541B relate to Form CMS-2567?
Both certification blocks say the facility was found in compliance unless indicated otherwise on the related Form CMS-2567.
Which regulations does the form name?
The complaint survey certification says the signer reviewed the requirements of 42 CFR 489.24 and the related provisions of 42 CFR 489.20.
Does Form CMS-1541B have an OMB number?
No. The form is marked Exempt, and the CMS page lists its O.M.B. number as EXEMPT.