How to fill cms 417 1984 form-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Identifying Information' section. Enter the name of your hospice, street address, city, county, state, and zip code.
3. In the 'Request to Establish Eligibility In' section, check the box for Medicare and provide your Medicare provider number if applicable.
4. Select the type of hospice from the options provided. Check one box that best describes your facility.
5. Complete the 'Type of Control' section by checking one option that reflects your organization’s structure (e.g., Non-Profit or Proprietary).
6. In 'Services Provided', indicate whether services are provided directly or through arrangements by placing a '1' or '2' in the appropriate blocks.
7. Fill out the number of employees/volunteers in each category as required in Section V.
8. Finally, ensure all information is accurate and sign where indicated before submitting.

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