The due date will result in cessation of program payments 2026

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

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