Official Federal Forms > Centers For Medicare And Medicaid Services
Extended-Partial Extended Survey Worksheet CMS-673 - Official Federal Forms
| Extended-Partial Extended Survey Worksheet Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES EXTENDED/PARTIAL EXTENDED SURVEY WORKSHEET FACILITY STANDARD OR ABBREVIATED SURVEY DATES _____/_____/_____ to _____/_____/_____ Mo Day Yr Mo Day YrPROVIDER NO. EXTENDED/PARTIAL EXTENDED SURVEY DATES _____/_____/_____ to _____/_____/_____ Mo Day Yr Mo Day Yr Extended Survey: Substandard care determined during Standard Survey resulting in Extended Survey. Partial Extended Survey: Substandard care determined during Abbreviated Survey resulting in Partial Extended Survey.Check all requirements not met that resulted in the Extended or Partial Extended Survey. 483.13 483.15 483.25 Document observations from extended/partial extended survey Tag/Concern (continued on back) Form CMS-673 (07/95) <<<<<<<<<********>>>>>>>>>>>>> 2Document observations from extended/partial extended survey (continued)Tag/ConcernForm CMS-673 (07/95)
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