I. Identifying Information
CMS Certification Number, State/County Code, State/Region Code, name of ASC, street address, city, state, ZIP code and a 10 digit telephone number.
CMS-377
AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE
- Agency
- CMS
- Revision
- 2024-11-21
- Fillable fields
- 32
- Pages
- 3
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-377: Ambulatory Surgical Center Request for Certification in Medicare
Form CMS-377 is the Ambulatory Surgical Center Request for Initial Certification or Update of Certification Information in the Medicare Program, from the Centers for Medicare & Medicaid Services (CMS). The CMS forms page lists it as Ambulatory Surgical Center Request for Certification in Medicare. Its instructions say that submitting it starts the process of obtaining a decision on whether the Conditions for Coverage are met.
The form says the ambulatory surgical center (ASC) completes and signs it for initial certifications, and on request of the State agency for periodic recertification. Page 1 has five sections: identifying information, type of control, ancillary services, surgical specialties and facility characteristics. Page 2 is an attestation statement signed by an ASC representative, and page 3 holds the instructions.
The instructions say to return the original and two copies to the State Survey Agency and keep a copy. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-377
II. Type of Control
One box only: Proprietary, Government or Non-Profit.
III. Ancillary Services
Laboratory, radiology and pharmaceutical services, each with a dropdown: 1 if provided directly, 2 if provided by an outside source by arrangement, 3 if both. No selection if the service is not provided.
IV. Surgical Specialties
Check all that apply: Dental, Endoscopy, Ear Nose & Throat, OB/GYN, Ophthalmologic, Orthopedic, Pain, Podiatry, Plastic/Reconstruction and Other, with space to specify.
V. Facility Characteristics
Number of operating rooms, number of procedure rooms and the date this ASC began providing services.
Attestation statement
A certification that the responses are true and correct to the best of the signer's knowledge, with a warning about false statements, then the representative's printed name, title, signature and date signed.
Page 1 has five numbered sections, coded AS1 to AS9. The attestation is AS10.
How to fill out Form CMS-377
- 1
Fill in identifying information
Enter the ASC's ten digit CMS Certification Number, or leave it blank on an initial request. The instructions say the ASC leaves the State/County and State/Region codes blank.
- 2
Pick the type of control
Check only one box in Section II: Proprietary, Government or Non-Profit.
- 3
Choose ancillary services
For each service in Section III, select 1, 2 or 3 from the dropdown. The instructions say to make no selection for a service that is not provided.
- 4
Check surgical specialties
Mark each category of surgery the ASC offers. The instructions say Other should include only broad categories, not subspecialties, and more than one block may be checked.
- 5
Add facility characteristics
Enter the number of operating rooms and procedure rooms and the date the ASC began providing services.
- 6
Sign and send it
The ASC representative signs the attestation. The instructions say to return the original and two copies to the State Survey Agency and keep a copy.
These steps follow the instructions on page 3. The form says to answer all questions as of the current date.
Why fill Form CMS-377 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
Where it goes and help
Where to send it
The instructions say to return the original and two copies of the completed form to the State Survey Agency and retain a copy.
Finding the State Survey agency
The form says the name and address of the State Survey agency for the ASC's area may be obtained from the appropriate CMS Location, formerly called the CMS Regional Office.
Help with the form
The instructions say assistance in completing the form is available from the State Survey agency for the area in which the ASC is located.
OMB number and time
OMB No. 0938-0266, approval expires 11/30/2027. The PRA statement calls it a mandatory collection and estimates an average of 30 minutes per response.
Not for the PRA office
The form says not to send applications, claims, payments, medical records or other sensitive documents to the PRA Reports Clearance Office address it lists for comments.
Related forms
CMS-370
HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER
10 fields, 2 pages
CMS-2802D
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER
35 fields, 1 page
CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
51 fields, 2 pages
CMS-2567
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
22 fields, 5 pages
CMS-417
HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE
117 fields, 17 pages
CMS-359
CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE
46 fields, 5 pages
Who uses Form CMS-377?
The form is for ambulatory surgical centers, not patients.
Official sources and the blank
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Questions about Form CMS-377
What is Form CMS-377?
It is the Ambulatory Surgical Center Request for Initial Certification or Update of Certification Information in the Medicare Program. The form says submitting it starts the process of deciding whether the Conditions for Coverage are met.
Who completes Form CMS-377?
The instructions say the ASC completes and signs it for initial certifications, and upon request of the State agency for the periodic recertification.
What if the ASC has no CMS Certification Number yet?
The instructions say to leave the CMS Certification Number blank on initial requests for certification.
How are ancillary services answered?
Select 1 if the facility provides the service directly, 2 if an outside source provides it by arrangement, 3 if both. Make no selection if the service is not provided.
Where does Form CMS-377 go?
The instructions say to return the original and two copies to the State Survey Agency and keep a copy for your files.
Where can I get help with the form?
The form says assistance is available from the State Survey agency for the area in which the ASC is located.