Official Federal Forms > Centers For Medicare And Medicaid Services
Request For Survey Of 489.20 And 489.24 Essentials Of Provider Agreements CMS-1541A - Official Federal Forms
| Request For Survey Of 489.20 And 489.24 Essentials Of Provider Agreements Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENTOF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES REQUEST FOR SURVEY OF 489.20 AND 489.24 ESSENTIALS OF PROVIDER AGREEMENTS: Responsibilities of Medicare Participating Hospitals in Emergency Cases 1. Name and Address of State Agency 2. Name and Address of Hospital 3. Provider Number RO Complaint Control Number4. Hospital Accredited By: JCAHO AOA Nonaccredited DO NOT INFORM THE HOSPITAL OF THE SURVEY 5. In Complaint Cases, Type of Emergency (check all that apply) Labor Other OB Medical Trauma Psychiatric Surgical Other6. Source of Complaint (check all that apply) Patient or Patients Family Quality Improvement Organization Receiving Hospital Medicare Intermediary Transferring Hospital Other (specify) Congressional Inquiry 7. In Complaint Cases, Type of Complaint (check all that apply) Physician on-call list Policies/Procedures Transfer Screening Treatment Posting of Signs Medical Records Reporting Requirement Whistleblower Recipient Hospital Responsibilities Delay in Examination or Treatment Central LogA copy of the allegation is enclosed.The name of the complainant should not be disclosed without specific authorization. Due to the serious nature of this complaint,please conduct the survey within 5 working days of notification. Signature of Regional Administrator or Designee Region Date Form CMS -1541A(4-95)
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