Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

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03-02 Form CMS 222-92 2990 (Cont.) FORM APPROVED OMB NO: 0938-0107 WORKSHEET S - PART I INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING For Intermediary Use FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET Date Received STATISTICAL DATA AND CERTIFICATION STATEMENT This report is required by law (42 USC. 1395g: CFR 413.20(b)). Failure to report can Intermediary Number result in all payments made during the reporting period being deemed overpayments (42 USC 1395g). PART I - STATISTICAL DATA [ ] Projected Cost Report [ ] Actual/Final Cost Report 1. Facility Name and Address 1a. County 2. Facility Number 3. Designation 4. Reporting Period From To 5. Type of Control (Check One) A. Voluntary Non Profit B. Proprietary C. Government [ ] Corporation [ ] Individual [ ] Partnership [ ] Federal [ ] County [ ] Other (Specify) [ ] Corporation [ ] Other (Specify) [ ] State [ ] Other (Specify) [ ] City 6. Source of Federal Funds GRANT AWARD DATE NUMBER A. Community Health Center (Section 330(d), Public Health Service Act) B. Migrant Health Center (Section 329 (d), PHS Act) C. Health Services for the Homeless (Section 340(d), PHS Act) D. Appalachian Regional Commission E . Look-Alikes F. Other (Specify) 7. Names of Physicians Furnishing Services At The Health Facility or Under Agreement (As Described In Instructions) And Medicare Billing Numbers (Include All Part B Billing Numbers) Name Billing Number 8. Supervisory Physicians Name Hours of Supervision For Reporting Period FORM CMS-222-92 (10/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903 and 2903.1) Rev. 5 29-303 80
2990 (Cont.) Form CMS 222-92 03-02 INDEPENDENT RURAL HEALTH CLINIC/ WORKSHEET S FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET PART I (Cont.) & STATISTICAL DATA AND CERTIFICATION STATEMENT PART II PART I (CONTINUED)-STATISTICAL DATA 9. If the facility operates as other than an RHC or FQHC (i.e., as a physicians office, independent laboratory, etc.) check yes and specify what type of operation and what days and hours RHC/FQHC services and other than RHC or FQHC services are provided at the facility as instructed below. YES [ ] NO [ ] Type of Operation ______________________________________________________________________ Identify days and hours by listing the time the facility operates as an RHC or FQHC next to the applicable da Sunday _____________________ Monday ____________________ Tuesday ____________________ Wednesday _________________ Thursday ____________________ Friday ______________________ Saturday ____________________ Identify days and hours by listing the time the facility operates as other than an RHC or FQHC next to the applicable day(s) Sunday _______________________ Monday ______________________ Tuesday ______________________ Wednesday ___________________ Thursday _______________________ Friday __________________________ Saturday ________________________ PART II - CERTIFICATION BY OFFICER OR ADMINISTRATOR MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COAT REPORT M BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UND FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROC THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT. CERTIFICATION BY OFFICER OR ADMINISTRATOR I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report prepared by (Provider Name and Number) for the cost report period beginning and ending and that to the best of my knowle and belief, it is a true, correct and complete statement prepared from the books and records of the Provider in accordance with the laws and regulations regarding the Provider in accordance with the laws and regulations regarding the provision of health care services and that the services identified in this cost report w provided in compliance with such laws and regulations. (Signed) Officer or Administrator of Facility Title Date According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0107. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850. FORM CMS-222-92 (10/96) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903 and 2903.2) 29-304 Rev. 5 81
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Arizona Rural Health Clinic Designa
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Community Environment & Policy 1295
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A. Background Information (con’t)
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B. Rural Health Clinics in Arizona
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C. Number of Rural Health Clinics i
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D. Frequently Asked Questions (con
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D. Frequently Asked Questions (con
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E. Steps to Becoming a Certified Ru
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B. Interpretive Guidelines for Rura
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Page 29 and 30: D. Preparing for the Certification
Page 37 and 38: 30 Most Common RHC Survey/Certifica
Page 39 and 40: F. RHC Cost Report The Medicare cos
Page 41 and 42: F. RHC Cost Report (con’t) •Wor
Page 43 and 44: F. RHC Cost Report (con’t) 11) Li
Page 45 and 46: G. Important Resources (con’t) -A
Page 47 and 48: Appendix A. Important Contact Infor
Page 49 and 50: Appendix B. Definitions for Rural H
Page 51 and 52: Appendix C. Federal Primary Care HP
Page 53 and 54: Appendix • C. Federal Primary Car
Page 55 and 56: Appendix D. Federal MUAs in Arizona
Page 57 and 58: Instructions for completing HCI App
Page 59 and 60: A. PLEASE LIST IN THE SPACE PROVIDE
Page 61 and 62: MEDICAL FACILITIES LICENSING 150 N.
Page 63 and 64: ARIZONA DEPARTMENT OF HEALTH SERVIC
Page 65 and 66: MEDICAL FACILITIES LICENSING 150 N.
Page 67 and 68: http://www.azdhs.gov/als/forms/otcs
Page 69 and 70: Appendix F. Certification Forms 1.
Page 71 and 72: 3. Has successfully completed a for
Page 73 and 74: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 75 and 76: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 77 and 78: According to the Paperwork Reductio
Page 79: MEDICARE ENROLLMENT APPLICATION INS
Page 83 and 84: RURAL HEALTH CLINIC SURVEY REPORT F
Page 85 and 86: NAME CODE YES NO N/A EXPLANATORY ST
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