Form preview

CMS-116 2010 free printable template

Get Form
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0581 clinical laboratory improvement amendments (CIA) application for certification i. General
pdfFiller is not affiliated with any government organization

Get, Create, Make and Sign CMS-116

Edit
Edit your CMS-116 form online
Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.
Add
Add your legally-binding signature
Draw or type your signature, upload a signature image, or capture it with your digital camera.
Share
Share your form instantly
Email, fax, or share your CMS-116 form via URL. You can also download, print, or export forms to your preferred cloud storage service.

Editing CMS-116 online

9.5
Ease of Setup
pdfFiller User Ratings on G2
9.0
Ease of Use
pdfFiller User Ratings on G2
To use our professional PDF editor, follow these steps:
1
Log in to account. Start Free Trial and register a profile if you don't have one yet.
2
Prepare a file. Use the Add New button. Then upload your file to the system from your device, importing it from internal mail, the cloud, or by adding its URL.
3
Edit CMS-116. Add and change text, add new objects, move pages, add watermarks and page numbers, and more. Then click Done when you're done editing and go to the Documents tab to merge or split the file. If you want to lock or unlock the file, click the lock or unlock button.
4
Get your file. Select your file from the documents list and pick your export method. You may save it as a PDF, email it, or upload it to the cloud.
With pdfFiller, it's always easy to work with documents.

Uncompromising security for your PDF editing and eSignature needs

Your private information is safe with pdfFiller. We employ end-to-end encryption, secure cloud storage, and advanced access control to protect your documents and maintain regulatory compliance.
GDPR
AICPA SOC 2
PCI
HIPAA
CCPA
FDA

CMS-116 Form Versions

Version
Form Popularity
Fillable & printabley
4.9 Satisfied (38 Votes)
4.9 Satisfied (40 Votes)
4.3 Satisfied (218 Votes)
4.2 Satisfied (71 Votes)
4.1 Satisfied (56 Votes)
4.4 Satisfied (459 Votes)
4.4 Satisfied (50 Votes)
4.0 Satisfied (38 Votes)

How to fill out CMS-116

Illustration

How to fill out CMS-116

01
Obtain a copy of the CMS-116 form from the official CMS website or your local CMS office.
02
Begin by filling out the identifying information at the top of the form, including your name, address, and contact information.
03
Provide details about the health care services you are requesting reimbursement for, including specific dates and types of services.
04
Include any relevant case numbers or patient identifiers as required.
05
List the providers involved and their National Provider Identifier (NPI) numbers.
06
Calculate the total amount claimed for each service and ensure it matches supporting documentation.
07
Attach any necessary documents, such as invoices or explanation of benefits, that support your claim.
08
Review all entries for accuracy and completeness before submitting.
09
Sign and date the form at the designated spot.
10
Submit the form via mail or electronically, as per the instructions provided.

Who needs CMS-116?

01
Healthcare providers and facilities that are seeking reimbursement from Medicare for services rendered to eligible beneficiaries.
02
Providers who need to appeal a denied claim or provide additional documentation for previously submitted claims.
03
Certain entities or organizations coordinating care or providing services under the Medicare program.

Who needs a CMS Form 116?

According to the United States Federal Law, every facility which deals with doing laboratory testings on humans (excluding basic researches and clinical trials) must comply with CIA standards. To be legally allowed to perform this type of activities, a laboratory facility has to be officially acknowledged as a clinical laboratory. The results achieved by such facilities are to be used for establishing diagnoses, preventing and treating diseases, and making general health condition assessments.

CIA regulations should be fulfilled even in case a laboratory performs one of few basic test free of charge.

What is the CIA Application for Certification Form for?

The Clinical Laboratory Improvement Amendments Application for Certification has been created to collect operation data about a laboratory facility. It will be used for defining the type of certificate to issue and fees to charge.

As for the types of CIA Certificates, they can be as follows:

    Certificate of Waiver

    Certificate for Provider-Performed Microscopy Procedures (PPM)

    Certificate of Compliance

    Certificate of Accreditation

However, typically if the CMS Form 116 is filed for the first time as an initial application, the laboratory in most will be issued a Certificate of Registration. Right after an inspection is conducted, another type of certificate will be provided.

Is Form CMS-116 accompanied by other forms?

It is strongly recommended that the applying facility contacts their State Agency for additional requirements as for supporting documentation, forms or statements as they vary from one state to another. In fact, this is true not only regarding the state of laboratory operation, but also regarding the type of CIA Certificate applied for. For instance, supervising personnel of laboratory where nonwaived tests and PPM procedures are performed must comply with certain requirements as for educational and training background and experience. Therefore, in such a case, the confirmation of these requirements being met must be attached to a completed CMS-116 form.

When is CMS Form 116 due?

A process of the CMS-116 application revision is quite time-consuming, as it can take up to two months. Nevertheless, a laboratory facility can start its work as soon as their payment of a registration fee is credited. And in about two weeks, the requested Certificate will be delivered.

The CIA Certificate is valid for two years. To renew the certificate in a timely manner, it is necessary to file a new CMS-116 form with no less than nine months prior to the effective certificate's expiration date. And if the form is filed and payment made until the due date, the renewed Certificate will be received one month before the current Certificate’s expiration date.

How do I fill out the CIA Application for Certification Form?

The application should provide relevant information on the following items:

    Facility’s general information (type of application, name, address, email, name of director, etc.);

    Type of requested certificate and appropriate testing (indicated further);

    Type of laboratory;

    Hours of testing;

    Single/multiple sites;

    Type of control;

    Director affiliation with other laboratories;

    Owner/director’s signature and date

Where do I send CMS Form 116?

The completed Clinical Laboratory Improvement Amendments Application for Certification must be submitted to the local State Agency in the State where the laboratory testing will be performed. The full list of addresses and other contact information can be found in this online PDF document.

Instructions and Help about CMS-116

Welcome to go beyond learning experiences to code Metro our goal in creating this series is to provide you with tangible oftentimes little-known tips that you can apply to both your business and your career our topics will vary as will our speakers, and we welcome you to visit our website to get the latest edition of go beyond we appreciate your feedback and invite you to send us your thoughts and questions as well as any suggestions you might have for future topics our first edition of go beyond focuses on tips for completing the CMS 1500 form for faster payment our presenter today is our own chief operating officer Dr. Kim finger Kim has an extensive background in autism having served as a direct service provider in Connecticut many years ago after which she swayed into the world of executive coaching prior to joining code Metro Kim was the chief operating officer at autism spectrum therapies a large California-based autism services company Kim created the insurance billing department at code Metro and is here to share with you her tips on completing the 1500 form hello it's my pleasure to share with you our tips on how to successfully complete a CMS 1500 form a question were frequently asked by our customers is which fields on the 1500 form must be completed for the CMS form to be accepted and not rejected by the insurance carrier, so today we're going to answer this question as well as review which fields are optional to complete and which can be left blank we'll also be reviewing what information is entered in each of the mandatory and optional fields recognizing that the language on the 1500 form is foreign to most providers and a source of confusion when preparing the form okay let's take a look at the 1500 form there are 33 fields on the form of which two fields can always be left blank without worry and that's field 10d reserved for local use and field 15 if patient has had same or similar illness give first date now that we have those out of the way let's talk about the fields that must be completed to submit a clean claim before we go through the numbered fields let's start with entering the name and address of the insurance company in the top right-hand corner of the form, although you may be submitting the form electronically the name and address of the insurance carrier must be included in this space on the form itself field 1a is a required field in this field you will enter the patient's insurance policy number as indicated on their insurance card in some cases the card will be in the parents name and their policy number will be entered here the ID number though will reflect not the parent but the patient's insurance ID number fields 2 camp; 5 capture patient name and address and must be completed the only optional field is telephone number fields 4 camp; 7 will contain the same name and address as fields 2 camp; 5 although the name on the insurance card may be the mother or father's name recent changes dictate that the patient...

Fill form : Try Risk Free
Users Most Likely To Recommend - Summer 2025
Grid Leader in Small-Business - Summer 2025
High Performer - Summer 2025
Regional Leader - Summer 2025
Easiest To Do Business With - Summer 2025
Best Meets Requirements- Summer 2025
Rate the form
4.4
Satisfied
50 Votes

People Also Ask about

The CLIA application (Form CMS-116) collects information about your laboratory's operation which is necessary to determine the fees to be assessed, to establish baseline data and to fulfill the statutory requirements for CLIA. This information will also provide an overview of your facility's laboratory operation.
For a change in certificate type you must complete the CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION FOR CERTIFICATION marked for a change in certificate type. Make sure you follow instructions to complete and submit all the requested information including the List of Tests Performed in the Facility.
What is a Waived Test? Based on the complexity of the tests, CLIA tests are categorized into three levels: waived, moderate complexity, and high complexity tests. CLIA defines waived tests as “Simple laboratory examinations and procedures that have an insignificant risk of an erroneous result.”
The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing (except research) performed on humans in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA). In total, CLIA covers approximately 320,000 laboratory entities.
For a change in certificate type you must complete the CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION FOR CERTIFICATION marked for a change in certificate type. Make sure you follow instructions to complete and submit all the requested information including the List of Tests Performed in the Facility.
Can I transfer my CLIA certificate to the new owners? Yes. The new owners can request a transfer by completing a CMS-116 Application Form and a CLIA Ownership Information form" found under CERTIFICATION & FEES on webpage.

Our user reviews speak for themselves

Read more or give pdfFiller a try to experience the benefits for yourself
5
A God send tool, don't want to think of processing work without PDFfille
Anonymous Customer
5
PDFfiller is really easy to use, and it helped me send off important documentation from the comfort of my home!
Kija M

For pdfFiller’s FAQs

Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

You can quickly improve your document management and form preparation by integrating pdfFiller with Google Docs so that you can create, edit and sign documents directly from your Google Drive. The add-on enables you to transform your CMS-116 into a dynamic fillable form that you can manage and eSign from any internet-connected device.
You can. With pdfFiller, you get a strong e-signature solution built right into your Chrome browser. Using our addon, you may produce a legally enforceable eSignature by typing, sketching, or photographing it. Choose your preferred method and eSign in minutes.
Use the pdfFiller mobile app to fill out and sign CMS-116 on your phone or tablet. Visit our website to learn more about our mobile apps, how they work, and how to get started.
CMS-116 is a form used by the Centers for Medicare & Medicaid Services to collect information regarding the provision of hospice services and to ensure compliance with federal regulations.
Hospice providers participating in Medicare or Medicaid programs are required to file CMS-116.
To fill out CMS-116, providers must provide accurate information regarding their hospice services, including details about the organization, services offered, and compliance with Medicare conditions of participation.
The purpose of CMS-116 is to ensure that hospice providers meet the necessary standards to deliver care under Medicare and Medicaid and to monitor that they adhere to regulations.
CMS-116 must include information such as the provider's name, address, services provided, administration details, and compliance with applicable standards.
Fill out your CMS-116 online with pdfFiller!

pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.

Get started now
Form preview

Related Forms

If you believe that this page should be taken down, please follow our DMCA take down process here .
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.