Beneficiary name and address
Two boxes at the top for the beneficiary's name and address.
CMS-36P
CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION
- Agency
- CMS
- Revision
- 07/20
- Fillable fields
- 4
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-36P: Consent for Home Visit for PACE Services Evaluation
Form CMS-36P is the Consent for Home Visit for PACE Services Evaluation from the Centers for Medicare & Medicaid Services. It is a one-page consent in which a beneficiary agrees to have State/Federal health survey personnel conduct a home visit. The form gives two purposes for the visit: to ensure that the Federal requirements are met, and to assist in evaluating the effectiveness and quality of home health services the beneficiary receives from a named PACE organization.
The form states that consent for the visit is voluntary, that no rights to confidentiality or privacy are waived by consenting, and that refusing a home health visit has no effect on the level or nature of PACE benefits the beneficiary is currently receiving. The CMS page lists the OMB number as exempt and also offers a Spanish version.
The form has fields for the beneficiary's name and address, the name of the PACE organization, and the signature of the beneficiary or a representative, with the date. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-36P
Consent to a home visit
A statement consenting to a home visit by State/Federal health survey personnel to ensure Federal requirements are met and to assist in evaluating the effectiveness and quality of home health services.
Name of PACE organization
A blank line in the consent statement for the PACE organization that provides the home health services.
Voluntary consent notice
A statement that consent is voluntary, that no rights to confidentiality or privacy are waived, and that refusing has no effect on the level or nature of current PACE benefits.
Signature and date
The signature of the beneficiary or the beneficiary's representative, and the date.
The whole form fits on one page, printed as Form CMS-36 P (07/20).
How to fill out Form CMS-36P
- 1
Read the consent statements
The form explains what the home visit is for and states that consent is voluntary and that refusing has no effect on current PACE benefits.
- 2
Enter name and address
Fill in the beneficiary's name and address in the boxes at the top.
- 3
Name the PACE organization
Write the name of the PACE organization that provides the home health services on the blank line.
- 4
Sign and date
The beneficiary, or the beneficiary's representative, signs and dates the form.
Why fill Form CMS-36P on indox
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- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
What the form says
Where it goes
The form does not print a mailing address or say who collects it. It names State/Federal health survey personnel as the people conducting the visit.
Voluntary consent
The form says consent for the visit is voluntary, and that refusing a home health visit has no effect on the level or nature of PACE benefits currently received.
Privacy
The form says none of the beneficiary's rights to confidentiality or privacy are waived by giving consent.
Spanish version and accessibility
The CMS page offers a Spanish version (CMS 36P-Spanish) and links to the CMS Accessibility & Nondiscrimination for Individuals with Disabilities Notice.
OMB status
The CMS page lists the OMB number for Form CMS-36P as exempt.
Related forms
Who uses Form CMS-36P?
The form names the beneficiary, a representative, the PACE organization and the survey personnel.
Official sources and the blank
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Questions about Form CMS-36P
What is Form CMS-36P for?
It is a consent for State/Federal health survey personnel to make a home visit, to ensure Federal requirements are met and to help evaluate the home health services a beneficiary receives from a PACE organization.
Does a beneficiary have to agree to the home visit?
The form says consent for the visit is voluntary, and that refusing a home health visit has no effect on the level or nature of PACE benefits the beneficiary is currently receiving.
Does signing Form CMS-36P give up privacy rights?
No. The form says none of the beneficiary's rights to confidentiality or privacy are waived by consenting.
Who can sign Form CMS-36P?
The signature line is for the beneficiary or a representative of the beneficiary, with the date.
Is Form CMS-36P available in Spanish?
Yes. The CMS page for Form CMS-36P lists a Spanish version alongside the English one.
Where is Form CMS-36P sent?
The form does not print a mailing address or say who collects it.