Get the free Facility Attestation of Termination

This document is a formal request to terminate the registration of a radiation producing machine in compliance with NAC 459.166. It requires accurate information and documentation to avoid denial of the termination request.

How to fill out facility attestation of termination

How to fill out facility attestation of termination

1. Begin by downloading the Facility Attestation of Termination form from the appropriate regulatory website.
2. Fill in the facility's name and address at the top of the form.
3. Provide the date of termination of services or programs.
4. Complete the section related to the reason for termination, ensuring to provide clear and concise information.
5. List any affected individuals or services involved in the termination.
6. Include any necessary attachments that support the termination statement.
7. Sign and date the form in the designated area.
8. Submit the completed form to the relevant authority as per their submission guidelines.

Who needs facility attestation of termination?

1. The facility owner or administrator must complete the attestation.
2. Any staff members involved in the termination process may also need to sign off.
3. Regulatory bodies or funding agencies expecting notification of termination need the completed form.

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What is facility attestation of termination?

Facility attestation of termination is a formal declaration submitted by a healthcare facility to confirm that it has ceased operations or has terminated its participation in a specific program, typically related to Medicare or Medicaid.

Who is required to file facility attestation of termination?

Healthcare facilities that decide to discontinue their participation in Medicare or Medicaid programs are required to file a facility attestation of termination.

How to fill out facility attestation of termination?

To fill out the facility attestation of termination, the authorized representative of the facility must complete the designated form, providing required details including the facility name, address, and the reason for termination, and then submit it to the relevant governing authority.

What is the purpose of facility attestation of termination?

The purpose of facility attestation of termination is to officially notify the governing bodies that the facility has ended its operations or participation, ensuring that records are updated and preventing future claims or issues related to the facility.

What information must be reported on facility attestation of termination?

The information that must be reported includes the facility's name, address, Medicare or Medicaid identification numbers, the effective date of termination, and the reason for termination.