Pdf fillable form cms 672 1998-2025

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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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Versions	Form popularity	Fillable & printable
2012	4.9 Satisfied (411 Votes)
2010	4 Satisfied (45 Votes)
1998	4.3 Satisfied (63 Votes)

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Where can I get CMS forms?

Hard copy forms may be available from Intermediaries, Carriers, State Agencies, local Social Security Offices or End Stage Renal Disease Networks that service your State.

What is a CMS 672 form?

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS. (use with Form HCFA 672) GENERAL INSTRUCTIONS. THIS FORM IS TO BE COMPLETED BY THE FACILITY AND REPRESENTS THE CURRENT. CONDITION OF RESIDENTS AT THE TIME OF COMPLETION.

What is the CMS-671 form?

CMS-671, Long-Term Care Facility Application for Medicare and Medicaid.

Is the CMS 672 no longer required?

Effective 10/22/23, the CMS-672 form is no longer in use and has been replaced with a revised CMS-671 form.

Is CMS only for Medicare?

The Centers for Medicare and Medicaid Services (CMS) provides health coverage to more than 100 million people through Medicare, Medicaid, the Childrens Health Insurance Program, and the Health Insurance Marketplace.

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