Pdf fillable form cms 672 1998-2026

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The document is a form from the Department of Health and Human Services, specifically the Centers for Medicare & Medicaid Services, designed to collect data on resident census and conditions in healthcare facilities. It outlines various categories for assessing residents' independence in activities of daily living (ADLs), mobility, mental status, skin integrity, special care needs, medications, and other characteristics. The form aims to provide a comprehensive overview of the current condition of residents at the time of completion, ensuring accurate representation for surveys.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Provider Number at the top of the form. This is essential for identifying your facility.
In Block F75, F76, and F77, input the number of residents under Medicare, Medicaid, and other payers respectively. Ensure accuracy as these figures represent your current resident census.
Proceed to the Activities of Daily Living (ADLs) section (F79-F93). For each activity like bathing, dressing, and transferring, indicate how many residents require assistance versus those who are independent.
Complete sections A through G by specifying the number of residents in each category based on their conditions and care needs. Use clear definitions provided in the form to guide your entries.
Finally, certify the information by signing at the bottom of the form. Make sure to include your title and date for validation.

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