08-14 bFORM CMSb-1984-14 4390 Cont Rev 1 43-101 - iahhc-2025

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The document is a detailed cost and data report form (CMS-1984-14) required for hospice providers to submit financial information related to their operations. It includes sections for reporting costs, statistical data, reimbursement questionnaires, balance sheets, and statements of revenues and expenses. The form emphasizes compliance with federal laws and regulations, requiring accurate reporting of financial data, including salaries, expenses, and patient care services. It also outlines the consequences of misrepresentation in the submitted information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your PROVIDER CCN and the reporting PERIOD (FROM and TO dates) at the top of the form.
In PART I - COST REPORT STATUS, select the appropriate status of your cost report from the options provided.
Complete PART II - CERTIFICATION by filling in your name, title, and date, ensuring you certify that all information is accurate.
Proceed to fill out HOSPICE IDENTIFICATION DATA, including details like provider name, address, and certification date.
For each section under WORKSHEET S and other parts, carefully input data as required. Use our platform's features to easily navigate between sections.
Review all entries for accuracy before submitting. Utilize our platform’s review tools to ensure completeness.

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Versions	Form popularity	Fillable & printable
2021	4.5 Satisfied (59 Votes)
2014	4.6 Satisfied (60 Votes)

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