F1 to F4: Survey dates
From and to dates (mm/dd/yyyy) for the standard survey and the extended survey, completed by the survey team.
CMS-671
LTC Facility Application for Medicare/Medicaid
- Agency
- CMS
- Revision
- 09/2023
- Fillable fields
- 50
- Pages
- 4
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-671: Long-Term Care Facility Application for Medicare and Medicaid
Form CMS-671 is the Long-Term Care Facility Application for Medicare and Medicaid from the Centers for Medicare & Medicaid Services. Its general instructions say the form is completed by the facility, and that for the purpose of the form, the facility equals certified beds, meaning Medicare and/or Medicaid certified beds. The survey team completes the survey dates at the top and three questions at the end of page 2.
The facility's part runs from block F5 to F32: identification, resident counts by payer, the type of facility, hospital ties, ownership, multi-facility organization, beds in dedicated special care units, resident and family groups, experimental research, continuing care retirement community status, staffing waivers and a Nurse Aide Training and Competency Evaluation Program. Two pages of definitions explain each block. The form is marked OMB Exempt.
You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-671
F5 to F8: Facility identification
Facility name, provider number, fiscal year ending, street address, city, county, state, ZIP code, telephone number, and the State/County and State/Region codes.
F8a to F11: Residents and facility type
Resident counts for Medicare, Medicaid, other and total; the facility type code (SNF, NF or SNF/NF); and whether the facility is hospital based, with the hospital provider number.
F12 to F14: Ownership
One of 13 ownership codes under for-profit, non-profit and government, whether a multi-facility organization owns or leases the facility, and that organization's name.
F15 to F27: Special care units and programs
Beds in dedicated special care units such as AIDS, Alzheimer's Disease, dialysis, hospice and ventilator/respiratory care, and yes or no for a residents' group, a family group, experimental research and CCRC status.
F28 to F32 and signature
Seven day RN and 24 hour licensed nursing waivers with approval dates and hours waived per week, a Nurse Aide Training and Competency Evaluation Program question, and the name, time, signature and date of the person completing the form.
Pages 1 and 2 hold the blocks. Pages 3 and 4 are definitions.
How to fill out Form CMS-671
- 1
Leave the survey blocks blank
F1 to F4 and the three questions at the end of page 2 are for the survey team. The definitions also say to leave the State/County and State/Region codes blank.
- 2
Identify the facility
Use the official name for business and mailing. The definitions say to leave the provider number blank on initial certifications and enter the six-digit code on recertifications, and to give the physical street address.
- 3
Count residents and pick the type
F8a counts residents whose stay is covered by the Medicare Part A SNF benefit and F8b those covered by a state's NF benefit. F9 takes 01 (SNF), 02 (NF) or 03 (SNF/NF).
- 4
Enter the ownership code
F12 takes the code for the organization that controls and operates the facility. The definitions give examples: 01 for a for-profit facility owned by an individual, 09 for one owned by a city government.
- 5
Answer beds and yes or no blocks
Enter beds in each dedicated special care unit and answer F24 to F27 and F32. The definitions explain each term, such as a CCRC operating under State regulation.
- 6
Report waivers and sign
For each staffing waiver, write the date of last approval and hours waived per week, or NA if there is no waiver. Then add the name of the person completing the form, the time, signature and date.
Why fill Form CMS-671 on indox
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What the form says
Where it goes
The form does not print a mailing address or say where to send it. Its survey dates and survey team questions are completed by the survey team.
The facility means certified beds
The general instructions say that for this form, the facility equals certified beds, meaning Medicare and/or Medicaid certified beds.
Staffing waivers
Blocks F28 to F31 apply if the facility has a nurse staffing waiver granted by CMS or the State Agency under 42 CFR 483.35(e) or (f).
Medication error rate
The survey team records the medication error rate at the time of survey, based on surveyor observation, as a whole number percentage up to 999.
OMB status
Each page of the form is marked OMB Exempt, and the CMS page lists the OMB number as exempt.
Related forms
Who uses Form CMS-671?
The form says it is completed by the facility. Some blocks are for the survey team or the State Survey Office.
Official sources and the blank
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Questions about Form CMS-671
Who completes Form CMS-671?
The general instructions say the facility completes it. The survey team fills in the survey dates and the questions on the ombudsman and medication error rate.
What does the facility mean on Form CMS-671?
The form says that for its purposes, the facility equals certified beds, meaning Medicare and/or Medicaid certified beds.
What goes in the provider number?
The definitions say to leave it blank on initial certifications and, on all recertifications, to insert the facility's assigned six-digit provider code.
How are dedicated special care unit beds counted?
The definitions say F15 to F23 take the number of beds the facility has identified and dedicated for residents with specific needs or diagnoses. Their example: 8 beds set aside for head injuries are shown as 8 in F19.
What if the facility has no staffing waiver?
The form says to write NA in the waiver blanks if the facility does not have a waiver.
What counts as experimental research on the form?
The definitions say it means using residents to develop and test clinical treatments, such as a new drug or therapy, that involves treatment and control groups, for example a clinical trial of a new drug.
Where is Form CMS-671 sent?
The form does not print a mailing address or say where to send it.