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Responsibilites Of Medicare Participating Hospitals In Emergency Cases Investigation CMS-1541B - Official Federal Forms
| Responsibilites Of Medicare Participating Hospitals In Emergency Cases Investigation 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 RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT 1. Name of Facility 2. Street Address 3. City and/or County 4. State 5. ZIP Code 6. Hospital Provider No. 7. Name of CEO 8. Telephone No. 9. State/Region Code 10.State/County Code 11. Dates of Survey (Begin) ______ / ______ / ______ (End) ______ / ______ / ______ MM DD CCYY MM DD CCYY12. Medicare/Medicaid 13.R O Complaint Control No. SA Complaint Control No. 14.Type of Survey No.of Certified Beds F Complaint F Resurvey SA Recommendation F None F In Compliance but Previously Out of Compliance F Recommend Termination (23 day) F Request Physician Review F Recommend Termination(90 day) F Possible Discrimination 1. Number of emergency cases seen per month for 2. Number of transfers of emergency patients to other each of the preceding 6 months acute hospitals per month for each of the preceding 6 months Month/Year # of Cases Month/Year # of Cases 3. Total Number of cases/medical records reviewed 4. Number of violations of 42 CFR 5. Number of violations of 42 CFR as a part of this investigation and the related 489.24 identified 489.20 identified provisions of 42 CFR 489.20 FFF FFF FFF For Complaint Survey: I certify that I have reviewed the requirements of 42 CFR 489.24 and the related provisions of 42 CFR 489.20 and, unless indicated on this form, the facility was found to be in compliance with the standards. For Resurvey: For the purpose of a resurvey, I certify that I have reviewed the requirements found not to be in compliance during the survey on and unless indicated on this form the facility was found to be in compliance with those requirements. Signature Title Date Signature Title Date Signature Title Date Signature Title Date Signature Title Date Signature Title Date Signature Title Date Signature Title Date FORM CMS-1541B (4-95)
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