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The due date will result in cessation of program payments 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the hospital's name and address in the designated fields. Ensure accuracy as this information is crucial for identification.
- Fill in the Medicare and Medicaid provider numbers. These identifiers are essential for processing your report correctly.
- Specify the period covered by the statement, ensuring that both 'From' and 'To' dates are accurately filled out to avoid any discrepancies.
- Complete the sections regarding types of control and type of hospital. Select appropriate options from the dropdown menus provided.
- In the certification section, ensure that an authorized officer or administrator signs and dates the form, confirming its accuracy and completeness.
- Review all entries for correctness before submitting. Any errors may lead to delays or cessation of program payments.
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