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

More documents

Recommendations

Info

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
NAME CODE YES NO N/A EXPLANATORY STATEMENTS J6 ■ MET ■ NOT MET II. §481.5 Location of Clinic. J7 ■ MET ■ NOT MET (a) Basic requirement. The clinic is located in a rural area that is designated as a shortage area, and may be a permanent or a mobile unit. J8 (1) Permanent unit. The objects, equipment and supplies necessary for the provision of the services furnished directly by the clinic are housed in a permanent structure. If clinic services are regularly furnished at permanent units in more than one location, each unit will be independently considered for certification as a rural health clinic. J9 (2) Mobile unit. The objects, equipment and supplies necessary for the provision of the services furnished directly by the clinic are housed in a mobile structure which has a fixed, scheduled location(s). List schedule of operation — day, time and location Form CMS-30 (05/78) EF 10/2004 2 85
Page 1 and 2:
Arizona Rural Health Clinic Designa
Page 3 and 4:
Community Environment & Policy 1295
Page 5 and 6:
A. Background Information (con’t)
Page 7 and 8:
B. Rural Health Clinics in Arizona
Page 9 and 10:
C. Number of Rural Health Clinics i
Page 11 and 12:
D. Frequently Asked Questions (con
Page 13 and 14:
D. Frequently Asked Questions (con
Page 15 and 16:
E. Steps to Becoming a Certified Ru
Page 17 and 18:
B. Interpretive Guidelines for Rura
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
D. Preparing for the Certification
Page 31 and 32:
D. Preparing for the Certification
Page 33 and 34: D. Preparing for the Certification
Page 35 and 36: 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 and 80: MEDICARE ENROLLMENT APPLICATION INS
Page 81 and 82: 2990 (Cont.) Form CMS 222-92 03-02
Page 83: RURAL HEALTH CLINIC SURVEY REPORT F
Page 87 and 88: NAME CODE YES NO N/A EXPLANATORY ST
show all

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

Create successful ePaper yourself

Delete template?

Save as template?