Civil rights information request for medicare certification 2018-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Healthcare Provider Information' section. Enter your CMS Medicare Provider Number, facility name, address, and contact details including the administrator's name and telephone number.
3. Indicate the type of facility and corporate affiliation. Specify the reason for application by circling either 'Initial Medicare Certification' or 'Change of Ownership'.
4. In the 'Documents Required for Submission' section, ensure you have all necessary documents ready. This includes the Assurance of Compliance form and your Nondiscrimination Policy.
5. Provide a detailed description of how you disseminate your nondiscrimination policies. Include methods such as brochures or postings.
6. Complete any additional required fields regarding communication procedures for individuals with disabilities or limited English proficiency.
7. Finally, review all entered information for accuracy before signing and dating the certification at the end of the form.

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