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Cms 1572-2026
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- Click ‘Get Form’ to open the cms 1572 in the editor.
- Begin with Part 1, where facility staff must fill in the Name of Facility, Provider Number, Street Address, Telephone, and Name of Administrator. Ensure all information is accurate and up-to-date.
- In the Administrator Qualification section, select the appropriate qualification type by marking '1' for RN or other relevant options.
- Indicate if there has been a change of ownership since the last survey by selecting 'Yes' or 'No'.
- If applicable, provide details about co-located hospice services and any branch locations operated by your agency.
- For Services Provided, indicate how each service is delivered by selecting from options such as HHA staff or Under Arrangement.
- List full-time equivalents for staffing under both Direct Hire Staff and Staff Under Arrangement in the designated sections.
- Finally, complete the form by entering your name, title, and date completed before saving your work.
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