Exhibits Table of Contents

Medicare State Operations Manual Chapter 9 - Exhibits Exhibits (Rev. 242; Issued: 05-29-26) Exhibit Description Download 1A Model Letter Transmitting Materials to Providers http://www.cms.gov/manuals/downloads/som107c09_exhibits.pdf 1B-1 Model Letter Transmitting CLIA Application and CMS- 855 to Laboratories http://www.cms.gov/manuals/downloads/som107c09_exhibitstoc.pd f 1C Model Letter transmitting Forms to Persons Furnishing Portable X- Ray Services http://www.cms.gov/manuals/downloads/som107_exhibit_001c.pdf 1D Model Letter Transmitting Materials to Rural Health Clinics http://www.cms.gov/manuals/downloads/som107_exhibit_001d.pdf 1E Model Letter to Operational ESRD Facility Requesting Initial Approval http://www.cms.gov/manuals/downloads/som107_exhibit_001e.pdf 2 Civil Rights Clearance for Medicare Provider Certification http://www.hhs.gov/ocr/civilrights/resources/providers/medicare_pr oviders/index.html 4 Health Insurance Benefits Agreement, CMS- 1561 https://www.cms.gov/medicare/forms-notices/cms-forms-list 4B Health Insurance Benefits Agreement, CMS- 1561A (Rural Health Clinics) https://www.cms.gov/medicare/forms-notices/cms-forms-list 7 Statement of Deficiencies and Plan of Correction, CMS-2567 https://www.cms.gov/medicare/forms-notices/cms-forms-list 7A Principles of Documentation http://www.cms.gov/manuals/downloads/som107_exhibit_007a.pdf 8 Post-Certification Revisit Report, CMS- 2567B https://www.cms.gov/medicare/forms-notices/cms-forms-list 9 Medicare/Medicaid Certification and Transmittal, CMS- 1539 and User Guide Located in National Database and Electronic Form is available at: https://www.cms.gov/medicare/health-safety-standards/certification- compliance 12 Survey Report Form (CLIA), CMS-1557 https://www.cms.gov/Medicare/CMS-Forms/CMS- Forms/downloads/cms1557.pdf 14C Skilled Nursing Facility and Intermediate Care Facility Crucial Data Extract, CMS-519E Located in the National Surveyor Database 14D Home Health Agency Survey Report, CMS- 1572 https://www.cms.gov/medicare/forms-notices/cms-forms-list 14H Outpatient Physical Therapy Survey Report - Crucial Data Extract, CMS-1893E Delete 14I ESRD Facility Survey Report- Crucial Data Extract, Form CMS- 3427E (To be used with Part II of Form CMS- 3427) http://www.cms.gov/manuals/downloads/som107_exhibit_014i.pdf 14J Rural Health Clinic Survey Report - Crucial Data Extract, CMS-30E Delete 14K Intermediate Care Facility - Individuals with Intellectual Disabilities Survey Report-Crucial Data Extract, CMS-3070B(E) Delete 14L Ambulatory Surgical Center Report - Crucial Data Extract, CMS-378E Delete 14M Therapist in Independent Practice - Crucial Data Extract, CMS-3042E Delete 14O Hospice Survey Report - Crucial Data Extract, CMS-449E Delete 15 Regional Office Request for Additional Information, CMS-1666 Delete 16 Budget Request, Clinical Laboratory Improvement Amendments Program, Form CMS-102 https://scclia.cms.gov/SCCLIA/Default.aspx 21 Request For Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services, CMS-1856 Delete (replaced with CMS-381 Form) 22 Guidance to Distinguish Between the Priorities of Immediate Jeopardy and Non-Immediate Jeopardy-High in Nursing Home Allegations http://www.cms.gov/manuals/downloads/som107_exhibit_022.pdf 23 ACTS Required Fields http://www.cms.gov/manuals/downloads/som107_exhibit_023.pdf 26 Model Letter to Rural Health Clinic Ineligible to Participate http://www.cms.gov/manuals/downloads/som107_exhibit_026.pdf 27 Model Letter to Previously Approved Facility Requesting Approval to Expand or Add a New End Stage Renal Disease (ESRD) Service http://www.cms.gov/manuals/downloads/som107_exhibit_027.pdf 30 Model Letter to Facility Returning Application not Accompanied by Required Certificate of Need (Where Applicable) http://www.cms.gov/manuals/downloads/som107_exhibit_030.pdf 31 End Stage Renal Disease Survey Report and Deficiencies Report, CMS-3427 https://www.cms.gov/medicare/forms-notices/cms-forms-list 33 Request for Validation of Accreditation Survey, CMS-2802 https://www.cms.gov/medicare/forms-notices/cms-forms-list 37 Model Letter Announcing Validation Survey Of Deemed Status Provider/Supplier Delete 41 State Agency's Letter to Medicare SNF Seeking Readmission After Involuntary Termination http://www.cms.gov/manuals/downloads/som107_exhibit_041.pdf 42 Orientation & Basic Training Program for the Newly Employed Health Facility Surveyor http://www.cms.gov/manuals/downloads/som107_exhibit_042.pdf 45 State Agency Budget Expenditure Report, CMS-435 https://scclia.cms.gov/SCCLIA/Default.aspx 47 State Agency Budget List of Positions, CMS- 1465A of Positions, CMS- 1465A https://scclia.cms.gov/SCCLIA/Default.aspx 52 State Survey Agency Certification Workload Report, CMS-434 https://scclia.cms.gov/SCCLIA/default.aspx 54 State Agency Schedule for Equipment Purchases, CMS-1466 https://scclia.cms.gov/SCCLIA/Default.aspx 56 Request for Certification to Provide OPT/OSP- Initial and Extension Site Requests CMS-381 https://www.cms.gov/medicare/forms-notices/cms-forms-list 57 Model Letter Requesting Identification of Extension Units Delete 58 Example of a Regular Disallowance Letter Delete 59 Example of a Deferral Letter Delete 60 Example of a Disallowance Letter for Amounts Previously Deferred Delete 61 Example of an Audit Disallowance Letter Delete 63 List of Documents in Certification Packets (Initial Certifications Include Initial Denials) http://www.cms.gov/manuals/downloads/som107_exhibit_063.pdf 64 Ambulatory Surgical Center Request for Certification in the Medicare Program, CMS-377 https://www.cms.gov/medicare/forms-notices/cms-forms-list 65 Health Insurance Benefits Agreement, CMS- 370 https://www.cms.gov/medicare/forms-notices/cms-forms-list 72 Hospice Request for Certification in the Medicare Program, CMS- 417 https://www.cms.gov/medicare/forms-notices/cms-forms-list 73 State Agency Worksheets for Verifying Exclusions from the Prospective Payment System, CMS- 437 https://www.cms.gov/medicare/forms-notices/cms-forms-list 74 Survey Team Composition and Workload Report, CMS- 670 https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/som107_exhibit_074.pdf 75 Medicare/Medicaid Complaint Form, CMS- 562 Delete 76 Model Letter to Clinics, Rehabilitation Agencies and Public Health Agencies Initially Applying to Serve as Providers of Outpatient Occupational Therapy Services Delete 77 Model Letter to Approved Medicare Clinics, Rehabilitation Agencies and Public Health Agencies that Request to Add Outpatient Occupational Therapy Services Delete 80 Intermediate Care Facility for Individuals with Intellectual Disabilities Survey Report, Form CMS- 3070G https://www.cms.gov/medicare/forms-notices/cms-forms-list 80A Intermediate Care Facility for Individuals with Intellectual Disabilities Deficiencies Report, Form CMS- 3070H https://www.cms.gov/medicare/forms-notices/cms-forms-list 80B Individual Observation Worksheet (Intermediate Care Facility for Individuals with Intellectual Disabilities), Form CMS- 3070I https://www.cms.gov/medicare/forms-notices/cms-forms-list 81 Model Letter Requirements for Swing- Bed Approval in Hospitals http://www.cms.gov/manuals/downloads/som107_exhibit_081.pdf 82 Model Letter Approval Notification for Swing- Beds in a Hospital http://www.cms.gov/manuals/downloads/som107_exhibit_082.pdf 83 Model Letter Denial for Swing-Bed Approval In A Hospital http://www.cms.gov/manuals/downloads/som107_exhibit_083.pdf 85 Long Term Care Facility Application for Medicare and Medicaid, CMS-671 https://www.cms.gov/medicare/forms-notices/cms-forms-list 87 Extended/Partial Extended Survey Worksheet, CMS- 673 https://www.cms.gov/medicare/forms-notices/cms-forms-list 88 CMS Nursing Home Survey Forms Delete, Nursing Home Survey forms are found at https://www.cms.gov/medicare/provider-enrollment-and- certification/guidanceforlawsandregulations/nursing-homes. 89 Offsite Survey Preparation Worksheet, CMS-801 Delete, Nursing Home Survey forms are found at https://www.cms.gov/medicare/provider-enrollment-and- certification/guidanceforlawsandregulations/nursing-homes. 91 General Observations of the Facility, CMS-803 Delete, refer to above main link. 92 Kitchen/Food Service Observation, CMS- 804 Delete, refer to above main link. 93 Resident Review Worksheet, CMS- 805 http://www.cms.gov/cmsforms/ 94 Quality of Life Assessment, CMS- 806 A, B, and C http://www.cms.gov/cmsforms/ 95 Surveyor Notes Worksheet, CMS- 807 Delete, Nursing Home Survey forms are found at https://www.cms.gov/medicare/provider-enrollment-and- certification/guidanceforlawsandregulations/nursing-homes. 103 Instructions for the Home Health Functional Assessment Instrument (FAI) Delete 104 Consent For Home Visit, CMS-36 https://www.cms.gov/medicare/forms-notices/cms-forms-list 106 Laboratory Personnel Report (CLIA), CMS- 209 https://www.cms.gov/medicare/forms-notices/cms-forms-list 116 Budget Requests, Clinical Laboratory Improvement Amendments Program - CMS-102 https://scclia.cms.gov/SCCLIA/Default.aspx 117 1465A - State Agency Budget List of Position for CLIA Program https://scclia.cms.gov/SCCLIA/default.aspx 118 1466 – CLIA Program State Agency Schedul e for Equipment Purchases https://scclia.cms.gov/SCCLIA/Default.aspx 119 Planned Workload Report, Clinical Laboratory Improvement Amendments Program, CMS-105 https://scclia.cms.gov/SCCLIA/Default.aspx 122 OMB Circular No. A- 102, Subject: Uniform Administrative Requirements for Grant- In-Aid to State and Local Governments www.whitehouse.gov/omb/circulars 127 Attestation Statement for Exclusion from PPS for Fiscal Year Beginning: (Date) http://www.cms.gov/manuals/downloads/som107_exhibit_127.pdf 128 Model Consent for Hospice Home Visit http://www.cms.gov/manuals/downloads/som107_exhibit_128.pdf 129 Hospice Survey and Deficiencies Report, CMS-643 https://www.cms.gov/medicare/forms-notices/cms-forms-list 130 Model Letter to Entity Seeking Participation in Medicare as a Community Mental Health Center (CMHC) Providing Partial Hospitalization Services Delete 131 Community Mental Health Center Crucial Data Extract Delete 132 Public Health Service Act-Section 1916(c)(4) http://www.cms.gov/manuals/downloads/som107_exhibit_132.pdf 133 Health Insurance Benefit Agreement Delete (duplicative of above) 134 Model Letter Transmitting Requirements to a Hospital Requesting a Change in Status to a Critical Access Hospital (CAH) http://www.cms.gov/manuals/downloads/som107_exhibit_134.pdf 135 Model Letter Transmitting Swing- Bed Approval Notification in a Critical Access Hospital (CAH) http://www.cms.gov/manuals/downloads/som107_exhibit_135.pdf 136 Request for Survey of 42 CFR §489.20 and 42 CFR §489.24, Essentials of Provider Agreements: Responsibilities of Medicare Participating Hospitals in Emergency Cases, CMS-1541A https://www.cms.gov/Medicare/CMS-Forms/CMS- Forms/downloads/cms1541a.pdf 137 Responsibilities of Medicare Participating Hospitals in Emergency Cases Investigation Report, CMS-1541B https://www.cms.gov/medicare/forms-notices/cms-forms-list 138 EMTALA Physician Review Worksheet http://www.cms.gov/manuals/downloads/som107_exhibit_138.pdf 139 Model Letter to Provider (Send with Form CMS- 2567)(Immediate Jeopardy Does Not Exit) http://www.cms.gov/manuals/downloads/som107_exhibit_139.pdf 140 Model Letter Notifying Provider of Acceptance of Allegation of Compliance http://www.cms.gov/manuals/downloads/som107_exhibit_140.pdf 141 Model Letter Notifying Provider of Results of Revisit http://www.cms.gov/manuals/downloads/som107_exhibit_141.pdf 142 Model Letter to Provider (Imposition of Remedies) (Immediate Jeopardy Does Not Exist) http://www.cms.gov/manuals/downloads/som107_exhibit_142.pdf 143 Model Letter to Provider (Imposition of Remedies) (Immediate Jeopardy Exists) http://www.cms.gov/manuals/downloads/som107_exhibit_143.pdf 144 Notice of Imposition of a Civil Money Penalty (Insert to formal notice) http://www.cms.gov/manuals/downloads/som107_exhibit_144.pdf 145 Notification of Change in the Amount of the Civil Money Penalty http://www.cms.gov/manuals/downloads/som107_exhibit_145.pdf 146 Notice of Receipt of the Written Request of Waiver of Right to a Hearing http://www.cms.gov/manuals/downloads/som107_exhibit_146.pdf 147 Notice of Payment Amount Due and Payable http://www.cms.gov/manuals/downloads/som107_exhibit_147.pdf 147A Notice Of Payment Amount Due For Placement In Escrow (Iidr Complete Or Not Timely Requested- Facility Is Filing Formal Appeal) http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_147A.pd f 148 Notification of Deduction of Civil Money Penalty from Money Owing to the Provider http://www.cms.gov/manuals/downloads/som107_exhibit_148.pdf 149 Model Letter Critical Access Hospital (CAH) Denial for Medicare Participation http://www.cms.gov/manuals/downloads/som107_exhibit_149.pdf 150 Model Letter Critical Access Hospital (CAH) Approval Notification http://www.cms.gov/manuals/downloads/som107_exhibit_150.pdf 151 Model Letter Request For A Plan of Correction Following an Initial Critical Access Hospital (CAH) Survey http://www.cms.gov/manuals/downloads/som107_exhibit_151.pdf 152 Model Letter Critical Access Hospital (CAH) Termination Letter http://www.cms.gov/manuals/downloads/som107_exhibit_152.pdf 154 Notice of Initial Approval of End - State Renal Disease (ESRD) Facility http://www.cms.gov/manuals/downloads/som107_exhibit_154.pdf 155 End-Stage Renal Disease (ESRD) Denial Notice http://www.cms.gov/manuals/downloads/som107_exhibit_155.pdf 156 Provider Tie-In Notice, CMS-2007 https://www.cms.gov/medicare/forms-notices/cms-forms-list 157 Notice - Expansion and/or Additional Service (Approval, Partial Approval or Denial) of ESRD Facility http://www.cms.gov/manuals/downloads/som107_exhibit_157.pdf 158 Notice - Recertification of ESRD Facility (Not Used for Special Purpose Renal Dialysis Facilities) http://www.cms.gov/manuals/downloads/som107_exhibit_158.pdf 160 Notice to ESRD Facility - Alternative Sanction for failure to participate with Network Goals and Objectives http://www.cms.gov/manuals/downloads/som107_exhibit_160.pdf 161 Notice of Interim Approval of CAPD Services Delete 162 Model Letter Request for a Plan of Correction Following an Initial Survey for Swing-Bed Approval in a Hospital http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_162.pdf 163 Model Letter Termination Letter for Hospital Swing-Bed Services http://www.cms.gov/manuals/downloads/som107_exhibit_163.pdf 165 Notice to a Provider that Agreement Was Accepted http://www.cms.gov/manuals/downloads/som107_exhibit_165.pdf 165a Notice to a Deemed Provider/ Supplier that Agreement was Accepted http://www.cms.gov/manuals/downloads/som107_exhibit_165a.pdf 166 Notice of Approval of Supplier of Services http://www.cms.gov/manuals/downloads/som107_exhibit_166.pdf 167 CMS-576, CMS-576A, Organ Procurement Organization Application and Agreement https://www.cms.gov/medicare/forms-notices/cms-forms-list 168 Organ Procurement Organization Report Form Delete 169 United Network for Organ Sharing Members https://optn.transplant.hrsa.gov/about/search-membership/ 170 Model Letter: Organ Procurement Organization Denial - Failure to Meet Requirements Delete 171 Model Letter: Organ Procurement Organization Denial - Competing Applications Delete 172 Model Letter: Organ Procurement Organization Approval Delete 173 Model Letter: Organ Procurement Organization Notice of Termination Delete 174 Model Letter: Organ Procurement Organization Notice to Public and State Medicaid/Medicare Agencies Delete 175 Model Letter: Organ Procurement Organization Notice to Bordering OPOs Delete 176 Model Letter: Organ Procurement Organization Corrective Action Notice Delete 177 Attestation Statement for Federally Qualified Health Centers http://www.cms.gov/manuals/downloads/som107_exhibit_177.pdf 179 Information on Medicare Participation/Federally Qualified Health Centers http://www.cms.gov/manuals/downloads/som107_exhibit_179.pdf 180 Notice to Accredited Psychiatric Hospital of Involuntary Termination Delete 181 Notice to Hospital Provider of Involuntary Termination http://www.cms.gov/manuals/downloads/som107_exhibit_181.pdf 182 Notice of Termination to Supplier http://www.cms.gov/manuals/downloads/som107_exhibit_182.pdf 183 Model Public Notice of Medicare Termination of Hospital Provider Agreement http://www.cms.gov/manuals/downloads/som107_exhibit_183.pdf 185 Model Telegram- Notice of Termination to a Medicaid ICF/IID Following "Look Behind" Survey: Immediate and Serious Threat to Patient Health and Safety http://www.cms.gov/manuals/downloads/som107_exhibit_185.pdf 187 Notification to Previously Approved Supplier of a Pending Termination Delete 188 Notification: Voluntary Termination of Provider Agreement Approved http://www.cms.gov/manuals/downloads/som107_exhibit_188.pdf 189 Notification: Approval of Voluntary Termination of a Supplier http://www.cms.gov/manuals/downloads/som107_exhibit_189.pdf 190 Notification to Provider That Has Ceased or Is Ceasing Operations http://www.cms.gov/manuals/downloads/som107_exhibit_190.pdf 191 Notification to Supplier That Has Ceased or is Ceasing Operations http://www.cms.gov/manuals/downloads/som107_exhibit_191.pdf 192 Acknowledgment of Request for Hearing Delete 194 Model Letter Announcing to Deemed, Accredited Provider/Supplier Compliance with all Surveyed Medicare Conditions of Participation, Coverage or Certification after a Sample Validation or Substantial Allegation Survey http://www.cms.gov/manuals/downloads/som107_exhibit_194.pdf 195 Model Letter Announcing to Deemed, Accredited Provider/Supplier that the Facility Does Not Comply with all the Conditions of Participation, Coverage or Certification and That There is Immediate and Serious Threat to Patient Health and Safety http://www.cms.gov/manuals/downloads/som107_exhibit_195.pdf 196 Model Letter Announcing to Deemed Status Provider/Supplier after a Validation Survey that it does not Comply with all Medicare Conditions http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_196.pdf 197 Notice to Accredited Hospital Announcing Approval of Plan of Correction and Completion Schedule http://www.cms.gov/manuals/downloads/som107_exhibit_197.pdf 198 Model Letter Announcing Compliance with all Conditions of Participation after the Effectuation of an Acceptable Plan of http://www.cms.gov/manuals/downloads/som107_exhibit_198.pdf Correction 199 Model Letter Announcing to Deemed Status Provider/Supplier after a Substantial Allegation Survey that it will Undergo a Full Survey http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_199.pdf 200 Model Letter Acknowledging Complaint Alleging Noncompliance with 42 CFR 489.24 and/or the Related Requirements of 42 CFR 489.20 Investigation not warranted http://www.cms.gov/manuals/downloads/som107_exhibit_200.pdf 201 Model Letter Acknowledging Complaint Alleging Noncompliance with 42 CFR 489.24 and/or the Related Requirements of 42 CFR 489.20 Investigation warranted http://www.cms.gov/manuals/downloads/som107_exhibit_201.pdf 202 Model Letter Requesting QIO Review of a Possible Violation of 42 CFR 489.24 http://www.cms.gov/manuals/downloads/som107_exhibit_202.pdf 203 Model Letter Following Investigation Into Alleged Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20 Facility In Compliance http://www.cms.gov/manuals/downloads/som107_exhibit_203.pdf 204 Model Letter For Violation of 42 CFR 489.24: Preliminary Determination Letter (Immediate and Serious Threat) http://www.cms.gov/manuals/downloads/som107_exhibit_204.pdf 205 Model Letter For Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20: Preliminary Determination Letter (90 Day Termination Track) http://www.cms.gov/manuals/downloads/som107_exhibit_205.pdf 206 Model Letter To Complainant Following Investigation of Alleged Violation of 42 CFR 489.24 And/Or The Related Requirement of 42 CFR 489.20 Complaint Not Substantiated http://www.cms.gov/manuals/downloads/som107_exhibit_206.pdf 207 Model Letter To Complainant Following Investigation of Alleged Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20 Complaint Substantiated http://www.cms.gov/manuals/downloads/som107_exhibit_207.pdf 208 Model Letter For Referring Violation of 42 CFR 489.24 To The Office of Inspector General http://www.cms.gov/manuals/downloads/som107_exhibit_208.pdf 209 Model Letter For Referring Violation of 42 CFR 489.24 To The Regional Office for Civil Rights http://www.cms.gov/manuals/downloads/som107_exhibit_209.pdf 210 Model Letter For Past Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20 No Termination http://www.cms.gov/manuals/downloads/som107_exhibit_210.pdf 211 Model Letter For Violation of 42 CFR 489.24 And/Or The Related Provisions of 42 CFR 489.20 Notice of Termination http://www.cms.gov/manuals/downloads/som107_exhibit_211.pdf 212 Model Letter Requesting QIO Review of A Confirmed Violation of 42 CFR 489.24 For Purpose of Assessing Civil Monetary Penalties (CMPs) Or Excluding Physicians http://www.cms.gov/manuals/downloads/som107_exhibit_212.pdf 214 Model Letter Announcing to State Survey Agency the Requirements for Administering the Long Term Care Surveyor Minimum Qualifications Test (SMQT) http://www.cms.gov/manuals/downloads/som107_exhibit_214.pdf 216 Report on Initial Survey Activity http://www.cms.gov/manuals/downloads/som107_exhibit_216.pdf 217 Aging Report on Pending Initial Survey Activity http://www.cms.gov/manuals/downloads/som107_exhibit_217.pdf 219 Model Audit Disallowance Letter - Title XVIII Delete 220 Model Audit Disallowance Letter - Title XIX Delete 221 Example of Regular Disallowance Letter http://www.cms.gov/manuals/downloads/som107_exhibit_221.pdf 222 Audit Clearance Document http://www.cms.gov/manuals/downloads/som107_exhibit_222.pdf 223 Model Letter Announcing to Deemed, Accredited Provider/Supplier After a Sample Validation Survey That It Does Not Comply with all Conditions of Participation/Conditions for Coverage http://www.cms.gov/manuals/downloads/som107_exhibit_223.pdf 224 Notice to Accredited Laboratory Announcing Approval of Plan of Correction and Completion Schedule for Correcting Deficiencies http://www.cms.gov/manuals/downloads/som107_exhibit_224.pdf 225 Model Letter: Announcing Compliance With Applicable CLIA Conditions After A Sample Validation or Substantial Allegation of Noncompliance Survey http://www.cms.gov/manuals/downloads/som107_exhibit_225.pdf 227 Model Letter: Announcing to the CLIA- Exempt Laboratory After a Sample Validation or Substantial Allegation of Noncompliance Survey That It Does Not Comply With Application Program Requirements http://www.cms.gov/manuals/downloads/som107_exhibit_227.pdf 228 Model Letter: Announcing to the State Laboratory Program, After A Sample Validation or Substantial Allegation of Noncompliance Survey That a CLIA- Exempt Laboratory Does Not Comply With Applicable Program Requirements http://www.cms.gov/manuals/downloads/som107_exhibit_228.pdf 229 Model Letter: Announcing to the CLIA- Exempt Laboratory, That CMS Will Seek a Temporary Injunction or Restraining Order http://www.cms.gov/manuals/downloads/som107_exhibit_229.pdf 230 Model Letter: Announcing to the State Laboratory Licensure Program That CMS Will Seek a Temporary Injunction or Restraining Order to Enjoin Continued Operation http://www.cms.gov/manuals/downloads/som107_exhibit_230.pdf 231 Model Letter: Announcing to the CLIA- Exempt Laboratory, After a Sample Validation or Substantial Allegation of Noncompliance Survey That It Does Not Comply With Applicable Program Requirements (No Immediate Jeopardy) http://www.cms.gov/manuals/downloads/som107_exhibit_231.pdf 232 Model Letter: Announcing to the State Laboratory Program, After a Sample Validation or Substantial Allegation of Noncompliance Survey, That a CLIA- Exempt Laboratory Does not Comply With the Applicable Program Requirements (No Immediate Jeopardy) Program, After a Sample https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_232.pdf 237 Model Letter: Announcing to an Accredited Laboratory After a Sample Validation Survey or a Substantial Allegation of Noncompliance Survey That It Does Not Comply with all CLIA Conditions and That There Exists, Immediate Jeopardy to the Health and Safety of Individuals or That of the General Public http://www.cms.gov/manuals/downloads/som107_exhibit_237.pdf 238 Model Letter: Announcing to an Accredited Laboratory After a Sample Validation Survey That the Laboratory Does Not Comply With All the CLIA Conditions- No Immediate Jeopardy http://www.cms.gov/manuals/downloads/som107_exhibit_238.pdf 241 Model Letter: Announcing to Accredited Laboratory After a Substantial Allegation of Noncompliance Survey That the Laboratory Does Not Comply With All CLIA Conditions (Complaint) http://www.cms.gov/manuals/downloads/som107_exhibit_241.pdf 242 Request for Validation of Accreditation Survey for Laboratories, CMS- 2802A https://www.cms.gov/medicare/forms-notices/cms-forms-list 243 Model Letter: Announcing to a CLIA Exempt Laboratory That It Is In Compliance With the CLIA Conditions After a Sample Validation or Substantial Allegation of Noncompliance Survey http://www.cms.gov/manuals/downloads/som107_exhibit_243.pdf 244 Model Letter: Announcing to the State Laboratory Program, That A CLIA-Exempt Laboratory is in Compliance with the CLIA Conditions After a Sample Validation or Substantial Allegation of Noncompliance Survey http://www.cms.gov/manuals/downloads/som107_exhibit_244.pdf 249 Model Application Letter Notifying Transplant Hospital that a complete Medicare General Enrollment Health Care CMS-855A need to be completed Delete 250 Model Application Letter to Transplant Hospital Requiring Partial Medicare General Enrollment Health Care CMS-855A Delete 251 Model Letter for First Rejection of a Request for Medicare approval of one or more Organ Transplant Programs Delete 252 Model Reminder Letter for First Rejection of a Request for Medicare approval of one or more Organ Transplant Programs Delete 253 Organ Transplant Hospital Worksheet Delete 254 Model Letter: Notification to Applicant that Medicare General Enrollment Health Care Provider/Supplier Application Has Been Denied Delete, available via national surveyor database. 255A Notice to Accredited Laboratory Announcing Approval of Plan of Correction and Completion Schedule for Correcting Deficiencies http://www.cms.gov/manuals/downloads/som107_exhibit_255A.pdf 256 Form CMS-855 - Medicare and Other Federal Health Care Program General Enrollment Health Care Provider/Supplier Application Providers/Suppliers can enroll online using PECOS or the paper enrollment application is located at: https://www.cms.gov/medicare/enrollment-renewal/providers- suppliers/chain-ownership-system-pecos/enrollment-applications 257 Form CMS-855C - Medicare and Other Federal Health Care Program Change of Information Health Care Provider/Supplier Application Providers/Suppliers can enroll online using PECOS or the paper enrollment application is located at: https://www.cms.gov/medicare/enrollment-renewal/providers- suppliers/chain-ownership-system-pecos/enrollment-applications 258 Form CMS-855R - Medicare and Other Federal Health Care Program Individual Reassignment of Benefits Health Care Provider/Supplier Application Providers/Suppliers can enroll online using PECOS or the paper enrollment application is located at: https://www.cms.gov/medicare/enrollment-renewal/providers- suppliers/chain-ownership-system-pecos/enrollment-applications 259 Minimum Data Set Automation Contract/Agreement Approval RO Checklist http://www.cms.gov/manuals/downloads/som107_exhibit_259.pdf 260 MDS Key Field Correction Form Delete 261 Privacy Act Statement - Health Care Records http://www.cms.gov/manuals/downloads/som107_exhibit_261.pdf 262 Overview of MDS Version 2.0 Correction Policy for Locked Records Delete 263 Submission Timeframe for MDS Records Delete 264 Resident Census and Conditions of Residents - CMS-672 Delete. 265 Roster/Sample Matrix - CMS-802 https://www.cms.gov/medicare/forms-notices/cms-forms-list 266 Roster/Sample Matrix Provider Instructions (Use with Form CMS- 802) - CMS-802P Delete, refer to above Exhibit 265 267 Roster/Sample Matrix Instructions for Surveyors (Use with Form CMS-802) - CMS- 802S Delete 268 Facility Characteristics Delete 269 Facility Quality Measure/Indicator Report Delete 270 Resident Level Quality Measure/Indicator Report: Chronic Care Sample Delete 271 QM/QI Reports Technical Specifications: Version 1.0 Delete 272 Overview of MDS Submission Record Delete 273 Correction Policy Summary Matrix Delete 274 Definition of Important Dates in the RAI Process Delete 275 Attestation Statement for CMHCs Delete 277 Fiscal Intermediary (FI) Medicare Provider Billing Number Deactivation Letter Used by FI Delete 278 Model Denial Letter for CMHC Applicants- State Restrictions on Screening Delete 279 Model Letter - Notice of Findings for Noncompliance for CMHCs Delete 280 Model Letter - Notice of Termination of Provider Agreement for CMHCs Delete 281 Model Letter - CMHC That Has Ceased Operation Delete 282 Model Letter - Participation in Medicare as a CMHC Providing Partial Hospitalization Services (Including Threshold and Service Requirements) Delete 283 Model Letter - Notice of Failure to Meet Threshold and Service Requirements, CMHCs Delete 284 Model Denial Letter - To a Home Health Agency (HHA) That Requested a Branch Office Delete 285 Worksheet for OBQM & OBQI Reports – Pre- Survey Process and Sample Selection Delete 286 Hospital/CAH Medicare Database Worksheet http://www.cms.gov/manuals/downloads/som107_exhibit_286.pdf 287 Authorization by Deemed Provider/Supplier Selected for Validation Survey http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_287.pdf 288 Surveyor Worksheet For Swing-Beds http://www.cms.gov/manuals/downloads/som107_exhibit_288.pdf 289 Model Reciprocal Agreement Between States for Survey and Certification of Home Health Agencies and/or Hospices http://www.cms.gov/manuals/downloads/som107_exhibit_289.pdf 290 Model letter to HHAs Assigning Branch Identification Numbers Delete 291 Model Notice to Hospital/CAH of Collection of Data by the State Agency http://www.cms.gov/manuals/downloads/som107_exhibit_290.pdf 292 INSTRUCTIONS FOR COMPLETING THE DATA USE AGREEMENT (DUA) FORM CMS- R-0235 http://www.cms.gov/manuals/downloads/som107_exhibit_292.pdf 293 CMS DUA: ACTS SOR Attachment - P&A http://www.cms.gov/manuals/downloads/som107_exhibit_293.pdf 294 DUA Multi- Signature Addendum http://www.cms.gov/manuals/downloads/som107_exhibit_294.pdf 351 Ambulatory Surgical Center Infection Control Surveyor Worksheet http://www.cms.gov/manuals/downloads/som107_exhibit_351.pdf 352 Notice to a Provider/supplier that Agreement was not Accepted http://www.cms.gov/manuals/downloads/som107_exhibit_352.pdf 353 Report of a Hospital Death Associated with Restraint or Seclusion (Form CMS-10455) http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_353.pdf 354 Model Letter To Involved Resident, Resident Representative And/Or State Ombudsman – Opportunity To Provide Written Comment (Independent Informal Dispute Resolution (Idr) Has Been Requested) http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_354.pdf 355 Probes and Procedures for Appendix J, Part II- Interpretive Guidelines- Responsibilities of Intermediate Care Facilities for Individuals with Intellectual Disabilities http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_355.pdf 356 Critical Access Hospital (CAH) Recertification Checklist: Rural and Distance or Necessary Provider Verification http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_356.pdf 358 Sample Form for Facility Reported Incidents https://www.cms.gov/files/document/som107exhibit358.pdf 359 Follow-up Investigation Report https://www.cms.gov/files/document/som107exhibit359.pdf