Get the free CMS-484. U.S. Federal Form

Title: CMS484 Author: www.usafederalforms.com Subject: U.S. Federal Form: HHS CMS: CMS484 Keywords: CMS484, PDF CMS484, HHS CMS forms, HHS CMS publications, PDF ...

How to fill out cms-484 us federal form

Who needs cms-484 us federal form?

1. Healthcare Providers: The cms-484 form is primarily used by healthcare providers who provide home health services to Medicare beneficiaries. These providers are required to complete the form to document the services they have furnished to the patient.
2. Medicare Beneficiaries: The form may also be relevant for Medicare beneficiaries who are receiving home health services. They may need to provide certain information on the form, such as their Medicare number and details of the care received.

How to fill out cms-484 us federal form:

1. Patient Information: Begin by providing the necessary patient information in the designated fields. This includes the patient's name, address, and Medicare number. Ensure that the information is accurate and up to date.
2. Certificate of Medical Necessity (CMN): The form requires the completion of a CMN, which certifies that the patient is in need of home health services and meets the eligibility criteria. Provide accurate and complete information in this section.
3. Physician's Information: Include the details of the physician who has ordered the home health services for the patient. This includes their name, address, and National Provider Identifier (NPI) number.
4. Home Health Agency Information: Enter the name and address of the home health agency providing the services. Include their Medicaid Provider Number and their NPI number.
5. Services Provided: Describe the specific services that have been furnished to the patient. This may include skilled nursing, physical therapy, speech therapy, occupational therapy, or medical social services. Provide a detailed description of each service and the dates on which they were provided.
6. Physician's Certification: The physician who ordered the home health services must certify the need for such services by signing and dating the form. Make sure to obtain the necessary physician's signature and date of certification.
7. Billing Information: If applicable, include the billing information for the services rendered. This may include the charges, diagnosis codes, and any other relevant billing details.
8. Review and Submit: Review the completed form for accuracy and completeness. Make sure all required fields are filled out and all necessary signatures and dates are provided. Once you have verified the information, submit the form to the appropriate authority or home health agency.

Remember to consult the official instructions and guidelines provided with the cms-484 form to ensure that you accurately complete the form and meet all the requirements.

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