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Cms 417 2026
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- Click ‘Get Form’ to open the cms 417 in the editor.
- Begin by filling out Item I, providing the name of your hospice and its street address. Ensure that you insert the six-digit Medicare Certification Number if applicable.
- In Item IV, indicate how services are provided. Place a '1' for direct services, '2' for outside sources, or '3' for both. This helps clarify your service delivery model.
- Complete the sections regarding the type of control and number of employees/volunteers. Be sure to check all relevant boxes that apply to your hospice's structure.
- Finally, review all entries for accuracy before signing and dating the form at the bottom. Retain a copy for your records and submit it to your State Agency as instructed.
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