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Click ‘Get Form’ to open the insurance agreement PDF in the editor.
Begin by entering the name of your facility in the designated field at the top of the form. This identifies your Ambulatory Surgical Center.
Review each compliance condition listed in sections (A) through (F). Ensure you understand your obligations regarding Medicare beneficiaries and payment processes.
In the signature fields, provide the names and titles of authorized representatives from both your center and the Secretary of Health and Human Services. Make sure to sign where indicated.
Finally, enter the effective date of the agreement. This is crucial for establishing when your obligations begin.

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