Omb no 0938 0986-2026

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  1. Click ‘Get Form’ to open the OMB No. 0938-0986 in the editor.
  2. Begin by entering the facility name and address in the designated fields. Ensure accuracy as this information is crucial for identification.
  3. Fill in the related Medicare provider number, room numbers, and number of beds in the unit. This data helps establish compliance with Medicare regulations.
  4. Indicate the survey date and specify the request for exclusion for the cost reporting period. Use the calendar tool for precise date selection.
  5. For each criterion listed under Subpart B of Part 412, select 'YES', 'NO', or 'N/A' based on your hospital's compliance status. Be thorough and consult relevant departments if needed.
  6. Finally, ensure that all sections are completed accurately before saving or submitting your form through our platform.

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