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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the 'Provider Name' and 'Provider Number(s)' at the top of the form. Ensure that this information is accurate as it identifies your organization.
- In Section A, answer questions regarding ownership changes and participation status. If applicable, provide supporting documents such as sales agreements.
- Proceed to Section B to report financial data. Indicate whether your financial statements were audited, compiled, or reviewed, and attach necessary documentation if required.
- Complete Sections C through K by answering each question accurately. Attach any additional documentation requested for clarity and compliance.
- Finally, ensure that an authorized officer certifies the information provided by signing and dating the certification section at the end of the form.
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