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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0074
PROVIDER NUMBER
RURAL HEALTH CLINIC SURVEY REPORT
(J1)
NAME OF CLINIC STREET NUMBER CITY COUNTY STATE ZIP CODE
SURVEYED BY
SURVEYOR’S PROFESSIONAL TITLE
■ INITIAL SURVEY
■ RESURVEY (J2)
LIST ADDITIONAL SURVEYOR’S NAMES TITLE PARTICIPATION UNDER TITLES 18 AND 19
DATE SURVEYED
A clinic certified under Medicare will be deemed to meet
the standards for certification under Medicaid.
CODE YES NO N/A
J3
■ MET
■ NOT MET
EXPLANATORY STATEMENTS
CLINIC LICENSE NUMBER (IF APPLICABLE)
II. §481.4 Compliance with Federal, State and local laws.
The rural health clinic and its staff are in compliance with
applicable Federal, State and local laws and regulations.
PHYSICIAN(S) NAME LIC. NO. CERT. NO. REG. NO.
J4 ■ MET ■ NOT MET ■ N/A
(a) Licensure of clinic.
The clinic is licensed pursuant to applicable State and local law.
NURSE PRACTITIONER(S) NAME LIC. NO. CERT. NO. REG. NO.
J5 ■ MET ■ NOT MET
PHYSICIAN ASSISTANT(S) NAME LIC. NO. CERT. NO. REG. NO.
(b) Licensure, certification or registration of personnel.
Staff of the clinic are licensed, certified or registered in
accordance with applicable State and local laws.
OTHER LICENSED PERSONNEL – IDENTIFY
Form CMS-30 (05/78) EF 10/2004 1
84