Form preview

Get the free to be completed by the state survey agency

Get Form
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 2I21 PART I TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility
We are not affiliated with any brand or entity on this form

Get, Create, Make and Sign to be completed by

Edit
Edit your to be completed by 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 to be completed by form via URL. You can also download, print, or export forms to your preferred cloud storage service.

Editing to be completed by online

9.5
Ease of Setup
pdfFiller User Ratings on G2
9.0
Ease of Use
pdfFiller User Ratings on G2
Follow the steps below to take advantage of the professional PDF editor:
1
Check your account. If you don't have a profile yet, click Start Free Trial and sign up for one.
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 to be completed by. Rearrange and rotate pages, insert new and alter existing texts, add new objects, and take advantage of other helpful tools. Click Done to apply changes and return to your Dashboard. Go to the Documents tab to access merging, splitting, locking, or unlocking functions.
4
Get your file. Select the name of your file in the docs list and choose your preferred exporting method. You can download it as a PDF, save it in another format, send it by email, or transfer it to the cloud.
With pdfFiller, dealing with documents is always straightforward.

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

How to fill out to be completed by

Illustration

How to fill out to be completed by

01
Gather all necessary information and documents
02
Start by entering personal information, such as name, address, and contact information
03
Fill out any applicable sections specific to the form, such as employment history, education, or medical information
04
Review the completed form for accuracy and completeness before submitting
05
Submit the form according to the instructions provided

Who needs to be completed by?

01
The form needs to be completed by the individual specified in the instructions or required by the organization requesting the form.
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
4.9
Satisfied
39 Votes

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.

The easiest way to edit documents on a mobile device is using pdfFiller’s mobile-native apps for iOS and Android. You can download those from the Apple Store and Google Play, respectively. You can learn more about the apps here. Install and log in to the application to start editing to be completed by.
Make sure you get and install the pdfFiller iOS app. Next, open the app and log in or set up an account to use all of the solution's editing tools. If you want to open your to be completed by, you can upload it from your device or cloud storage, or you can type the document's URL into the box on the right. After you fill in all of the required fields in the document and eSign it, if that is required, you can save or share it with other people.
You can. With the pdfFiller Android app, you can edit, sign, and distribute to be completed by from anywhere with an internet connection. Take use of the app's mobile capabilities.
To be completed by refers to the section on a form or document that needs to be filled out by a specific individual or entity.
The individual or entity identified in the form or document as the recipient of the completed section is required to file to be completed by.
To fill out to be completed by, the individual or entity must provide accurate and relevant information as requested in the section.
The purpose of to be completed by is to ensure that the necessary information is provided by the appropriate person or entity for the completion of the form or document.
The specific information that must be reported on to be completed by will vary depending on the form or document in question.
Fill out your to be completed by 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
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.