Get the free CMS Form 359 - cms

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0267 INSTRUCTIONS FOR COMPLETING THE COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REQUEST

How to fill out cms form 359

How to Fill Out CMS Form 359:

1. Begin by obtaining a copy of CMS Form 359 from the Centers for Medicare & Medicaid Services (CMS) website or your healthcare provider.
2. Start by providing your personal information in the designated section of the form. This may include your name, address, phone number, and date of birth.
3. Next, you may need to enter your Medicare Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI). You can find this information on your Medicare card or any Medicare-related correspondence.
4. Identify the type of claim you are filing by checking the appropriate box. This form is commonly used for institutional claims, including those for hospital stays, nursing facility services, or other inpatient care.
5. In the subsequent sections of the form, provide detailed information about the services or treatment received. This may include the dates of service, the diagnosis codes, and the procedure codes associated with the care provided.
6. If applicable, provide any additional documentation or attachment required to support your claim. This may include medical records, itemized bills, or supporting documents from other healthcare providers.
7. Double-check your completed form for accuracy and completeness. Ensure that all necessary fields are filled out and all supporting documentation is included.
8. Once you have reviewed and verified the information, sign and date the form.

Who Needs CMS Form 359:

1. Hospitals: CMS Form 359 is commonly required for hospitals or other institutional healthcare facilities to submit claims for reimbursement from Medicare or Medicaid.
2. Nursing Facilities: Nursing homes or long-term care facilities also often utilize CMS Form 359 to file claims for services provided to Medicare or Medicaid beneficiaries.
3. Healthcare Providers: Some healthcare providers may need to use CMS Form 359 for specific cases involving inpatient care or other institutional services.

Remember, it is important to consult with your healthcare provider or contact CMS directly to determine if CMS Form 359 is the appropriate form for your specific circumstances.

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What is cms form 359?

CMS Form 359 is a form used to report changes in ownership for Medicare/Medicaid providers.

Who is required to file cms form 359?

Any Medicare/Medicaid provider undergoing a change in ownership is required to file CMS Form 359.

How to fill out cms form 359?

CMS Form 359 should be completed with accurate information about the change in ownership, including details about the new owner.

What is the purpose of cms form 359?

The purpose of CMS Form 359 is to notify Medicare/Medicaid of changes in ownership that may affect provider eligibility.

What information must be reported on cms form 359?

Information such as the old and new owner's details, effective date of ownership change, reason for change, and any additional documentation required.