Facility name and purpose
A line to insert the name of the facility, which the form then calls the Ambulatory Surgical Center, and the purpose: eligibility for payment under title XVIII.
CMS-370
HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER
- Agency
- CMS
- Revision
- 2024-11-21
- Fillable fields
- 10
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-370: Health Insurance Benefits Agreement for an Ambulatory Surgical Center
Form CMS-370 is the Health Insurance Benefits Agreement with an Ambulatory Surgical Center under section 1832(a)(2)(F) of the Social Security Act, from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. The form says it is for the purpose of establishing eligibility for payment under title XVIII of the Social Security Act.
Page 1 names the facility and lists six things the Ambulatory Surgical Center agrees to, (A) to (F), with terms on when the agreement is binding, how it can be terminated and what happens on a transfer of ownership. Page 2 has signature blocks for the ASC and for the Secretary of Health and Human Services, and the effective date of the agreement.
The Paperwork Reduction Act notice estimates an average of 1 hour per response. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-370
Items (A) to (C)
Maintain compliance with 42 CFR part 416 and report any failure to CMS, not charge a Medicare beneficiary or any other person for items or services for which the beneficiary is entitled to have payment made under part 416, and refund any money incorrectly collected.
Items (D) to (F)
Furnish CMS, if requested, information to set payment rates under 416.120 and 416.130, accept assignment for facility services under 416.85, and comply with requirements regarding the Quality Improvement Organization that contracts with CMS to review ambulatory surgical procedures.
Binding, termination and ownership terms
When the agreement becomes binding and effective, that either party may terminate it in accordance with regulations, and what happens after a transfer of ownership.
ASC signature block
Printed name, title and signature of the ASC representative, and the date signed, below a false statements warning from 18 U.S.C. section 1001.
HHS or CMS acceptance
Printed name, title and signature of the HHS or CMS representative, the date signed and the effective date of the agreement.
How to fill out Form CMS-370
- 1
Insert the facility name
Write the name of the facility on the line in the opening paragraph.
- 2
Read items (A) to (F)
Review the six commitments and the terms on binding effect, termination and transfer of ownership.
- 3
Complete the ASC block
On page 2, enter the ASC representative's printed name and title, then sign and date.
- 4
Leave the HHS or CMS block blank
The acceptance for the Secretary and the effective date are completed by the HHS or CMS representative. The form says the agreement becomes effective on the date the Secretary or the Secretary's delegate specifies.
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What the form and the CMS page say
Where it goes
The form prints no mailing address. Its CMS notice says to contact [email protected] with questions about where to submit documents.
When it is binding
The form says the agreement is binding on the ASC and the Secretary upon submission by the ASC and acceptance for filing by the Secretary of Health and Human Services.
Termination
Either party may terminate the agreement in accordance with regulations. The form says payment is not available for ASC services furnished on or after the effective date of termination.
OMB number and expiration
OMB No. 0938-0266, which the form says expires 11/30/2027. The CMS page lists a revision date of 2024-11-21.
Time to complete
The form estimates an average of 1 hour per response. The CMS address in its Paperwork Reduction Act notice is for comments on that estimate, not for the form.
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CMS-1561
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CMS-1561A
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CMS-576A
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CMS-1539
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Who uses Form CMS-370?
The agreement is between an Ambulatory Surgical Center and the Secretary of Health and Human Services.
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Questions about Form CMS-370
What is Form CMS-370?
It is the Health Insurance Benefits Agreement with an Ambulatory Surgical Center under section 1832(a)(2)(F) of the Social Security Act. The form says its purpose is establishing eligibility for payment under title XVIII.
Who signs Form CMS-370?
An ASC representative signs for the Ambulatory Surgical Center, and an HHS or CMS representative signs to accept for the Secretary of Health and Human Services.
When does the agreement take effect?
The form says it becomes effective on the date specified by the Secretary or the Secretary's delegate, and remains in effect unless terminated.
Can the agreement be ended?
The form says either party may terminate it in accordance with regulations, and payment is not available for ASC services furnished on or after the effective date of termination.
What happens if the ASC changes owners?
The form says that after a transfer of ownership, the agreement remains effective between the Secretary of Health and Human Services and the transferee.
Where is Form CMS-370 sent?
The form prints no mailing address. Its CMS notice gives [email protected] for questions about where to submit documents.