Fully Participating

5 - Fully Participating Participation of an institution in its entirety either in the Medicare or Medicaid program, or both. 2762C - Distributing Form CMS-1539 (Rev. 1, 05-21-04) The SA completes the five copies of Form CMS-1539. Copies are transmitted as follows: 1. First copy (white) - to the RO. 2. Second copy (yellow) - to the RO for a Medicare-only or a dually-participating facility, or the SMA for a Medicaid-only facility or any facility with a Medicaid- only distinct part. 3. Third copy (pink) - retain for SA files. 4. Fourth copy (green) - a convenience copy that the SA may use for cross filing. 5. Fifth copy (blue) - to the SMA. In the case of a Medicaid-only facility or Medicaid-only distinct part, the SMA is to transmit this copy to the RO by to indicate the issuance of a provider agreement. If Form CMS-1539 is computer generated, copies are distributed the same as above. 2762D - Amended Certifications (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) Should the additional information requested via the Regional Office Request for Additional Information (Form CMS-1666, see §2776) result in any changes in the certification, the SA prepares a new Form CMS-1539 incorporating the additional documentation and any resulting changes in the certification. The SA draws a line through the original Form CMS-1539 and note at the top of this form, “See amended certification dated .” The SA forwards Form CMS-1539 to the RO or MAC indicating in Item 16 that “this certification is amending the certification dated_______.”