Header
Related Medicare provider number, room numbers in the unit, facility name and address, number of beds, survey date, the cost reporting period for the exclusion request, and verified by.
CMS-437
PSYCHIATRIC UNIT CRITERIA WORKSHEET
- Agency
- CMS
- Revision
- 04/06
- Fillable fields
- 266
- Pages
- 8
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-437: Psychiatric Unit Criteria Worksheet
Form CMS-437 is the Psychiatric Unit Criteria Work Sheet from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. It records whether a psychiatric unit of a hospital meets the requirements for exclusion from Medicare's hospital prospective payment system (PPS). The form says all criteria must be met for exclusion.
The header asks for the related Medicare provider number, the room numbers and number of beds in the unit, the facility name and address, the survey date, the cost reporting period the exclusion is requested for, and who verified it. The rest is a table of tags A1105 to A1192, each with regulation text from sections 412.25 and 412.27, guidance questions, yes and no boxes and an explanatory statement column. It also has tables for physicians and nursing personnel.
The guidance questions refer to the state agency (SA) and the CMS Regional Office (RO). You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-437
Tags A1105 to A1112: common requirements
From section 412.25: being part of a participating hospital not excluded in its entirety from PPS, uniform written admission criteria, separately identified records, transfer of clinical information, State licensure, utilization review and physically separate beds.
Tags A1120 to A1122: admissions and services
From section 412.27: admitting only patients who need active treatment with a listed psychiatric principal diagnosis, furnishing psychological services, social work, psychiatric nursing, occupational therapy and recreational therapy, and maintaining medical records.
Tags A1130 to A1165: medical records
Assessment and diagnostic data, the psychiatric evaluation, the treatment plan, progress notes, and the discharge planning and discharge summary.
Tags A1170 to A1185: staffing
Personnel, the director and medical staff with a table of full-time, part-time and consulting physicians, and nursing services with nursing counts by shift and an R.N. duty roster for at least one complete week.
Tags A1186 to A1192: other services
Psychological services, social services with a director of social services, and a therapeutic activities program.
Each tag row has regulation, guidance, yes, no and explanatory statement columns.
How to fill out Form CMS-437
- 1
Complete the header
Enter the related Medicare provider number, room numbers, facility name and address, number of beds, survey date, the cost reporting period dates (MM DD YYYY) and who verified it.
- 2
Work through each tag
For each tag from A1105 to A1192, read the regulation and guidance, check yes or no, and use the explanatory statement column.
- 3
Fill in the physician table
Under tag A1182, enter the number of full-time, part-time and consulting physicians in psychiatry, neurology and other specialties, specifying each other specialty.
- 4
Fill in the nursing tables
Enter nursing full-time equivalents for R.N.s, L.P.N.s and aides, the day-of-survey counts by shift, the average bed-size of the adult patient ward, and the R.N. duty roster.
- 5
Review the criteria as a whole
The form says all criteria must be met for exclusion from Medicare's hospital prospective payment system (PPS).
Why fill Form CMS-437 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
Sending the form and what it says
Where to send it
The form and the CMS page do not print a mailing address. The CMS address in the Paperwork Reduction Act notice is given for comments on the time estimate or suggestions for improving the form.
Exclusion criteria
The form says all criteria must be met for exclusion from Medicare's hospital prospective payment system (PPS).
OMB number and dates
The form shows OMB No. 0938-0358 and prints Form CMS-437 (04/06) on each page. The CMS page lists a revision date of 2026-09-30 and an O.M.B. expiration date of 2024-10-31.
Time to complete
The form estimates an average of 15 minutes per response, including reviewing instructions and gathering the data.
Related forms
CMS-2802F
Authorization for State Agency Psychiatric Hospital Validation Survey
42 fields, 1 page
CMS-2567
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
22 fields, 5 pages
CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
51 fields, 2 pages
CMS-801
Offsite Survey Prep Worksheet
13 fields, 1 page
CMS-807
Surveyor Notes Worksheet
11 fields, 2 pages
Who uses Form CMS-437?
The worksheet is about a psychiatric unit inside a hospital, reviewed in a survey.
Official sources and the blank
Do it all with indox
No tool matches that search.
Questions about Form CMS-437
What is Form CMS-437 used for?
It is a worksheet that records whether a hospital psychiatric unit meets the requirements in sections 412.25 and 412.27 for exclusion from Medicare's hospital prospective payment system (PPS).
Do all criteria have to be met?
The form says all criteria must be met for exclusion from Medicare's hospital PPS.
What period does the exclusion request cover?
The header asks for the cost reporting period the exclusion is requested for, as a from and to date in MM DD YYYY.
What does the form say about the psychiatric evaluation?
Tag A1141 says the psychiatric evaluation is completed within 60 hours of admission. Other tags list what it includes, such as a medical history and a record of mental status.
How often are progress notes recorded, according to the form?
Tag A1161 says at least weekly for the first two months and at least once a month thereafter, with the frequency determined by the condition of the inpatient.
What staffing details does the form ask for?
The number of full-time, part-time and consulting physicians by specialty, nursing full-time equivalents for R.N.s, L.P.N.s and aides, day-of-survey nursing counts by shift, and an R.N. duty roster for at least one complete week.