484 Backer. Notice of Exclusions from Medicare BenefitsSkilled Nursing Facility (NEMB-SNF) - cms 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section A, enter the certification type and date. If this is an initial certification, mark ‘INITIAL’ and provide the required dates.
3. Fill in the patient’s information including name, address, telephone number, and HICN as it appears on their Medicare card.
4. Provide supplier information by entering your company name, address, telephone number, and NSC or NPI number.
5. Indicate the place of service where the item will be used. Include any relevant facility names if applicable.
6. Complete Section B by answering questions regarding medical necessity. Ensure that this section is reviewed by a physician before submission.
7. In Section C, describe all items ordered along with their costs and Medicare fee schedule allowances.
8. Finally, have the physician sign and date Section D to certify that all information is accurate and complete.

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