Pdf fillable form cms 672 1998-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Provider Number at the top of the form. This is essential for identifying your facility.
3. 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.
4. 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.
5. 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.
6. 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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