Medicare State Operations Manual 
Chapter 9 - Exhibits 
 
 
Exhibits 
(Rev. 208, 10-21-22) 
 
Exhibit  Description  Download 
1A   Model Letter  http://www.cms.gov/manuals/downloads/som107c09_exhibits.pdf 
Transmitting Materials to 
Providers 
1B-1   Model Letter  http://www.cms.gov/manuals/downloads/som107c09_exhibitstoc.pd
Transmitting CLIA  f  
Application and CMS-
855 to Laboratories 
1B-2   Model Letter  delete 
Transmitting CLIA 
Application and CMS-
1513 to Laboratories 
1B-3   Initial Forms Required by delete 
Laboratories for CLIA 
Registration 
1C   Model Letter transmitting http://www.cms.gov/manuals/downloads/som107_exhibit_001c.pdf 
Forms to Persons 
Furnishing Portable X-
Ray Services 
1D   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_001d.pdf 
Transmitting Materials to   
Rural Health Clinics 
1E  Model Letter to  http://www.cms.gov/manuals/downloads/som107_exhibit_001e.pdf 
Operational ESRD 
Facility Requesting 
Initial Approval 
1F  Model Letter  delete 
Transmitting Title XVIII 
Materials to Individual 
Requesting to Participate 
as a Physical Therapist in 
Independent Practice 
2  Civil Rights Clearance  http://www.hhs.gov/ocr/civilrights/resources/providers/medicare_pr
for Medicare Provider  oviders/index.html 
Certification  3  Expression of  delete 
Intermediary Preference 
4  Health Insurance  http://www.cms.gov/cmsforms/ 
Benefits Agreement, 
CMS-1561 
4B  Health Insurance  https://www.cms.gov/Medicare/CMS-Forms/CMS-
Benefits Agreement,  Forms/Downloads/CMS1561A.pdf 
CMS-1561A (Rural 
Health Clinics) 
5  Statement of Financial  Deleted 
Solvency, CMS-2572 
6  Ownership and Control  Deleted 
Interest Disclosure 
Statement, CMS-1513 
6   Errata Sheet to  Deleted 
Ownership and Control 
Interest Disclosure 
Statement, CMS-1513 
7  Statement of Deficiencies https://www.cms.gov/Regulations-and-
and Plan of Correction,  Guidance/Legislation/PaperworkReductionActof1995/PRA-
CMS-2567  Listing-Items/CMS-2567.html 
7A  Principles of  http://www.cms.gov/manuals/downloads/som107_exhibit_007a.pdf 
Documentation   
8  Post-Certification Revisit  http://www.cms.gov/cmsforms/ 
Report, CMS-2567B   
9  Medicare/Medicaid  http://www.cms.gov/cmsforms/ 
Certification and   
Transmittal, CMS-1539 
10  Certification and  delete 
Transmittal Spell of 
Illness Supplement, 
CMS-1539A 
12  Survey Report Form  https://www.cms.gov/Medicare/CMS-Forms/CMS-
(CLIA), CMS-1557  Forms/downloads/cms1557.pdf 
14A  Hospital Survey Report -  delete 
Crucial Data Extract, 
CMS-1537E 
14B  Fire Safety Survey  delete 
Report - Crucial Data 
Extract, CMS-2786E 
14C  Skilled Nursing Facility  Located in Aspen  and Intermediate Care 
Facility Crucial Data 
Extract, CMS-519E 
14D  Home Health Agency  Deleted 
Survey and Deficiencies 
Report, CMS-1572 
14H  Outpatient Physical  Located in Aspen 
Therapy Survey Report - 
Crucial Data Extract, 
CMS-1893E 
14I  ESRD Facility Survey  http://www.cms.gov/manuals/downloads/som107_exhibit_014i.pdf 
Report- Crucial Data 
Extract, Form CMS-
3427E (To be used with 
Part II of Form CMS-
3427) 
 
14J  Rural Health Clinic  Located in Aspen 
Survey Report - Crucial 
Data Extract, CMS-30E  
14K  Intermediate Care  Located in Aspen 
Facility - Individuals 
with Intellectual 
Disabilities Survey 
Report-Crucial Data 
Extract, CMS-3070B(E) 
14L  Ambulatory Surgical  Located in Aspen 
Center Report - Crucial 
Data Extract, CMS-378E 
14M  Therapist in Independent  Located in Aspen 
Practice - Crucial Data 
Extract, CMS-3042E 
14O  Hospice Survey Report -  Located in Aspen 
Crucial Data Extract, 
CMS-449E 
15  Regional Office Request  http://www.cms.gov/cmsforms/ 
for Additional   
Information, CMS-1666 
16  Budget Request, Clinical  https://scclia.cms.gov/SCCLIA/Default.aspx 
Laboratory Improvement   
Amendments Program, 
Form CMS-102 
  21  Request For Certification  http://www.cms.gov/cmsforms/ 
in the Medicare and/or   
Medicaid Program to 
Provide Outpatient 
Physical Therapy and/or 
Speech Pathology 
Services, CMS-1856  
22  Guidance to Distinguish  http://www.cms.gov/manuals/downloads/som107_exhibit_022.pdf 
Between the Priorities of   
Immediate Jeopardy and 
Non-Immediate 
Jeopardy-High in 
Nursing Home 
Allegations 
23  ACTS Required Fields  http://www.cms.gov/manuals/downloads/som107_exhibit_023.pdf 
 
24  Model Letter to Ineligible delete 
Physical Therapists 
Requesting to Participate 
as a Physical Therapist in 
Independent Practice 
25  Model Letter to Rural  Deleted 
Health Clinic Regarding 
Scheduling a Survey 
26  Model Letter to Rural  http://www.cms.gov/manuals/downloads/som107_exhibit_026.pdf 
Health Clinic Ineligible   
to Participate 
27  Model Letter to  http://www.cms.gov/manuals/downloads/som107_exhibit_027.pdf 
Previously Approved   
Facility Requesting 
Approval to Expand or 
Add a New End Stage 
Renal Disease (ESRD) 
Service 
30  Model Letter to Facility  http://www.cms.gov/manuals/downloads/som107_exhibit_030.pdf 
Returning Application   
not Accompanied by 
Required Certificate of 
Need (Where Applicable) 
31  End Stage Renal Disease  http://www.cms.gov/cmsforms/ 
Survey Report and   
Deficiencies Report, 
CMS-3427 
32  Model Letter Explaining  delete  to Provider That One-
Story Protected Wood 
Frame Facility Does Not 
Meet Sprinkler 
Equivalency Standard 
33  Request for Validation of  http://www.cms.gov/cmsforms/ 
Accreditation Survey,   
CMS-2802 
35  Survey Material   Deleted 
36  Instructions for  delete 
Completing Hospital 
Request for Certification 
in the Medicare/Medicaid 
Program, CMS-1514 
(Contains Authorization 
Statement for AOA and 
Joint Commission 
Hospitals) 
37  Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_037.pdf 
Announcing Validation   
Survey Of Deemed 
Status Provider/Supplier 
38  Model Form for  delete 
Certification of 
Chiropractors Where 
Requirements Prior to 
July 1, 1974 Apply 
39  Model Form for  delete 
Certification of 
Chiropractors Where 
Requirements After June 
30, 1974 Apply 
41  State Agency's Letter to  http://www.cms.gov/manuals/downloads/som107_exhibit_041.pdf 
Medicare SNF Seeking   
Readmission After 
Involuntary Termination 
42  Orientation & Basic  http://www.cms.gov/manuals/downloads/som107_exhibit_042.pdf 
Training Program for the   
Newly Employed Health 
Facility Surveyor 
45  State Agency Budget  https://scclia.cms.gov/SCCLIA/Default.aspx 
Expenditure Report, 
CMS-435   
47  State Agency Budget  https://scclia.cms.gov/SCCLIA/Default.aspx 
List of Positions, CMS-
1465A 
of Positions, CMS-
1465A 
52  State Survey Agency  https://63.148.94.170/MBESCBES/ 
Certification Workload   
Report, CMS-434 
54  State Agency Schedule  https://scclia.cms.gov/SCCLIA/Default.aspx 
for Equipment Purchases,  
CMS-1466   
56  Identification of  http://www.cms.gov/cmsforms/ 
Extension Units of   
OPT/OSP Providers, 
CMS-381 
57  Model Letter Requesting  http://www.cms.gov/manuals/downloads/som107_exhibit_057.pdf 
Identification of   
Extension Units 
58  Example of a Regular  http://www.cms.gov/manuals/downloads/som107_exhibit_058.pdf 
Disallowance Letter   
59  Example of a Deferral  http://www.cms.gov/manuals/downloads/som107_exhibit_059.pdf 
Letter   
60  Example of a  http://www.cms.gov/manuals/downloads/som107_exhibit_060.pdf 
Disallowance Letter for   
Amounts Previously 
Deferred 
61  Example of an Audit  http://www.cms.gov/manuals/downloads/som107_exhibit_061.pdf 
Disallowance Letter   
62  Model Letter - State  Deleted 
Agency Advising a 
Provider or Supplier of 
an Impending Federal 
63  List of Documents in  http://www.cms.gov/manuals/downloads/som107_exhibit_063.pdf 
Certification Packets   
(Initial Certifications 
Include Initial Denials) 
64  Ambulatory Surgical  http://www.cms.gov/cmsforms/ 
Center Request for   
Certification in the 
Medicare Program, 
CMS-377  65  Health Insurance  http://www.cms.gov/cmsforms/ 
Benefits Agreement, 
CMS-370 
69  Certification  delete 
Recommendation - CLIA 
Laboratory, CMS-197 
71  Fire Safety Survey  delete 
Report - Short Form, 
CMS-2786C 
72  Hospice Request for  http://www.cms.gov/cmsforms/ 
Certification in the   
Medicare Program, 
CMS-417 
73  State Agency Worksheets http://www.cms.gov/cmsforms/ 
for Verifying Exclusions   
from the Prospective 
Payment System, CMS-
437 
74  Survey Team  https://www.cms.gov/Regulations-and-
Composition and  Guidance/Guidance/Manuals/Downloads/som107_exhibit_074.pdf 
Workload Report, CMS-
670 
 
75  Medicare/Medicaid  http://www.cms.gov/cmsforms/ 
Complaint Form, CMS-  
562 
76  Model Letter to Clinics,  http://www.cms.gov/manuals/downloads/som107_exhibit_076.pdf 
Rehabilitation Agencies   
and Public Health 
Agencies Initially 
Applying to Serve as 
Providers of Outpatient 
Occupational Therapy 
Services 
77  Model Letter to  http://www.cms.gov/manuals/downloads/som107_exhibit_077.pdf 
Approved Medicare   
Clinics, Rehabilitation 
Agencies and Public 
Health Agencies that 
Request to Add 
Outpatient Occupational 
Therapy Services 
79  Model Letter to  delete 
Individuals Requesting  Participation in Medicare 
as Occupational 
Therapists in 
Independent Practices 
80  Intermediate Care  http://www.cms.gov/cmsforms/ 
Facility for Individuals 
with Intellectual 
Disabilities Survey 
Report, Form CMS-
3070G  
81   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_081.pdf 
Requirements for Swing-  
Bed Approval in 
Hospitals 
82   Model Letter Approval  http://www.cms.gov/manuals/downloads/som107_exhibit_082.pdf 
Notification for Swing-  
Beds in a Hospital 
83   Model Letter Denial for  http://www.cms.gov/manuals/downloads/som107_exhibit_083.pdf 
Swing-Bed Approval In   
A Hospital 
83B  Model Letter - Denial  delete 
For Swing-Bed Approval 
In A Hospital 
84   ESRD Facility Survey  delete 
Report Form - 
Addendum, CMS-3427A 
85   Long Term Care Facility  http://www.cms.gov/cmsforms/ 
Application for Medicare   
and Medicaid, CMS-671 
87   Extended/Partial  http://www.cms.gov/cmsforms/ 
Extended Survey   
Worksheet, CMS-673 
88   Medication Pass  http://www.cms.gov/cmsforms/ 
Worksheet, CMS-677   
89   Offsite Survey  http://www.cms.gov/cmsforms/ 
Preparation Worksheet,   
CMS-801 
91   General Observations of  http://www.cms.gov/cmsforms/ 
the Facility, CMS-803   
92   Kitchen/Food Service  http://www.cms.gov/cmsforms/ 
Observation, CMS-804    93   Resident Review  http://www.cms.gov/cmsforms/ 
Worksheet, CMS-805   
94   Quality of Life  http://www.cms.gov/cmsforms/ 
Assessment, CMS-806   
A, B, and C 
95   Surveyor Notes  http://www.cms.gov/cmsforms/ 
Worksheet, CMS-807   
96   OSCAR Report 3  delete 
(History Facility Profile) 
and OSCAR Report 4 
(Full Facility Profile) 
103   Instructions for the Home http://www.cms.gov/manuals/downloads/som107_exhibit_103.pdf 
Health Functional   
Assessment Instrument 
(FAI) 
104   Consent For Home Visit,  http://www.cms.gov/cmsforms/ 
CMS-36    
105   State Test Administration delete 
Plan 
106   Laboratory Personnel  https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-
Report (CLIA), CMS- Forms-Items/CMS008840.html 
209 
107   Request for Validation  delete 
Survey of Laboratory, 
CMS-2802A 
108   Laboratory Authorization delete 
Form 
110   Compliance Warning  delete 
Letter - Failure to Apply 
for Certificate 
111   Model Letter Notifying  delete 
Laboratory of Cited 
Deficiencies and 
Requesting a Plan of 
Correction 
112   Model Letter - CLIA  delete 
Requirements Not Met - 
Laboratory Out of 
Compliance 
113   Model Letter - CLIA  delete 
Requirements Not Met -  Immediate Jeopardy 
114   Model Letter Warning  delete 
CLIA Laboratory of 
Possible Sanction - 
Failure to Disclose 
Financial Interest and 
Ownership Information 
115  Model Letter - Change of  delete 
Ownership - Laboratories 
116   Budget Requests,  https://scclia.cms.gov/SCCLIA/Default.aspx 
Clinical Laboratory   
Improvement 
Amendments Program - 
CMS-102 
 
117  1465A - State Agency  http://63.148.94.170/mbescbes/ 
Budget List of Position 
for CLIA Program 
118  1466  CLIA Program  https://scclia.cms.gov/SCCLIA/Default.aspx 
State Agency     Schedule  
for Equipment Purchases 
119  Planned Workload  https://scclia.cms.gov/SCCLIA/Default.aspx 
Report, Clinical 
Laboratory Improvement 
Amendments Program, 
CMS-105 
 
120  Standard Form 1199A,  delete 
Direct Deposit Sign-Up 
Form 
121  Payment Management  Specific Items to Consider When Completing the Form  
System, SMARTLINK   CMS-1557 Deleted 
II, User's Manual 
122  OMB Circular No. A- www.whitehouse.gov/omb/circulars 
102, Subject: Uniform 
Administrative 
Requirements for Grant-
In-Aid to State and Local 
Governments 
123  Blood Bank Inspection  delete 
Checklist and Report, 
CMS-282 (Form FDA 
2609)  124  Laboratory Personnel  delete 
Report, CMS-114 
125  CLIA Laboratory  https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-
Application, CMS-              F   o  r m   s  -               
116  Items/CMS012169.html?DLPage=1&DLEntries=10&DLFilter=11
  6&DLSort=0&DLSortDir=ascending 
 
126  Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_126.pdf 
Accompanying Self-  
Attestation Worksheets 
127   Attestation Statement for  http://www.cms.gov/manuals/downloads/som107_exhibit_127.pdf 
Exclusion from PPS for   
Fiscal Year Beginning: 
(Date)  
128  Model Consent for  http://www.cms.gov/manuals/downloads/som107_exhibit_128.pdf 
Hospice Home Visit   
129   Hospice Survey and  http://www.cms.gov/cmsforms/ 
Deficiencies Report,   
CMS-643 
130   Model Letter to Entity  http://www.cms.gov/manuals/downloads/som107_exhibit_130.pdf 
Seeking Participation in   
Medicare as a 
Community Mental 
Health Center (CMHC) 
Providing Partial 
Hospitalization Services 
131   Community Mental  http://www.cms.gov/manuals/downloads/som107_exhibit_131.pdf 
Health Center Crucial   
Data Extract 
132   Public Health Service  http://www.cms.gov/manuals/downloads/som107_exhibit_132.pdf 
Act-Section 1916(c)(4)   
133   Health Insurance Benefit  http://www.cms.gov/manuals/downloads/som107_exhibit_133.pdf 
Agreement   
134   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_134.pdf 
Transmitting   
Requirements to a 
Hospital Requesting a 
Change in Status to a 
Critical Access Hospital 
(CAH) 
135   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_135.pdf 
Transmitting Swing-Bed   
Approval Notification in  a Critical Access 
Hospital (CAH) 
136  Request for Survey of 42  http://www.cms.gov/cmsforms/ 
CFR 489.20 and 42   
CFR 489.24, Essentials 
of Provider Agreements: 
Responsibilities of 
Medicare Participating 
Hospitals in Emergency 
Cases, CMS-1541A 
137  Responsibilities of  http://www.cms.gov/cmsforms/ 
Medicare Participating   
Hospitals in Emergency 
Cases Investigation 
Report, CMS-1541B 
138   EMTALA Physician  http://www.cms.gov/manuals/downloads/som107_exhibit_138.pdf 
Review Worksheet   
139   Model Letter to Provider  http://www.cms.gov/manuals/downloads/som107_exhibit_139.pdf 
(Send with Form CMS-  
2567)(Immediate 
Jeopardy Does Not Exit) 
140   Model Letter Notifying  http://www.cms.gov/manuals/downloads/som107_exhibit_140.pdf 
Provider of Acceptance   
of Allegation of 
Compliance 
141   Model Letter Notifying  http://www.cms.gov/manuals/downloads/som107_exhibit_141.pdf 
Provider of Results of   
Revisit 
142   Model Letter to Provider  http://www.cms.gov/manuals/downloads/som107_exhibit_142.pdf 
(Imposition of Remedies)  
(Immediate Jeopardy 
Does Not Exist) 
143   Model Letter to Provider  http://www.cms.gov/manuals/downloads/som107_exhibit_143.pdf 
(Imposition of Remedies)  
(Immediate Jeopardy 
Exists) 
144   Notice of Imposition of a  http://www.cms.gov/manuals/downloads/som107_exhibit_144.pdf 
Civil Money Penalty   
(Insert to formal notice) 
145   Notification of Change in http://www.cms.gov/manuals/downloads/som107_exhibit_145.pdf 
the Amount of the Civil   
Money Penalty 
146   Notice of Receipt of the  http://www.cms.gov/manuals/downloads/som107_exhibit_146.pdf  Written Request of   
Waiver of Right to a 
Hearing 
147   Notice of Payment  http://www.cms.gov/manuals/downloads/som107_exhibit_147.pdf 
Amount Due and Payable  
147A  Notice Of Payment  http://www.cms.gov/Regulations-and-
Amount Due For  Guidance/Guidance/Manuals/downloads/som107_exhibit_147A.pd
Placement In Escrow  f 
(Iidr Complete Or Not 
Timely Requested-
Facility Is Filing Formal 
Appeal) 
148   Notification of Deduction http://www.cms.gov/manuals/downloads/som107_exhibit_148.pdf 
of Civil Money Penalty   
from Money Owing to 
the Provider 
149   Model Letter Critical  http://www.cms.gov/manuals/downloads/som107_exhibit_149.pdf 
Access Hospital (CAH)   
Denial for Medicare 
Participation 
150   Model Letter Critical  http://www.cms.gov/manuals/downloads/som107_exhibit_150.pdf 
Access Hospital (CAH)   
Approval Notification 
151   Model Letter Request For http://www.cms.gov/manuals/downloads/som107_exhibit_151.pdf 
A Plan of Correction   
Following an Initial 
Critical Access Hospital 
(CAH) Survey 
152   Model Letter Critical  http://www.cms.gov/manuals/downloads/som107_exhibit_152.pdf 
Access Hospital (CAH)   
Termination Letter 
153   Notice of Technical  Deleted 
Denial - Certificate of 
Need Denied 
154   Notice of Initial  http://www.cms.gov/manuals/downloads/som107_exhibit_154.pdf 
Approval of End - State   
Renal Disease (ESRD)   
Facility 
155   End-Stage Renal Disease  http://www.cms.gov/manuals/downloads/som107_exhibit_155.pdf 
(ESRD) Denial Notice 
156  Provider Tie-In Notice,  http://www.cms.gov/cmsforms/ 
CMS-2007    157   Notice - Expansion  http://www.cms.gov/manuals/downloads/som107_exhibit_157.pdf 
and/or Additional Service  
(Approval, Partial 
Approval or Denial) of 
ESRD Facility 
158   Notice - Recertification  http://www.cms.gov/manuals/downloads/som107_exhibit_158.pdf 
of ESRD Facility (Not   
Used for Special Purpose 
Renal Dialysis Facilities) 
159   List of VA Hospitals  Delete 
Having Sharing 
Arrangements with 
Participating ESRD 
Hospitals 
160   Notice to ESRD Facility  http://www.cms.gov/manuals/downloads/som107_exhibit_160.pdf 
- Alternative Sanction for   
failure to participate with 
Network Goals and 
Objectives 
161   Notice of Interim  http://www.cms.gov/manuals/downloads/som107_exhibit_161.pdf 
Approval of CAPD   
Services 
162   Model Letter Request for  http://www.cms.gov/Regulations-and-
a Plan of Correction  Guidance/Guidance/Manuals/downloads/som107_exhibit_162.pdf 
Following an Initial 
Survey for Swing-Bed 
Approval in a Hospital 
163   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_163.pdf 
Termination Letter for   
Hospital Swing-Bed 
Services 
164   RO Adjudication of SA  Delete 
Certification Actions 
165   Notice to a Provider that  http://www.cms.gov/manuals/downloads/som107_exhibit_165.pdf 
Agreement Was   
Accepted 
165a  Notice to a Deemed  http://www.cms.gov/manuals/downloads/som107_exhibit_165a.pdf 
Provider/ Supplier that 
Agreement was Accepted 
166   Notice of Approval of  http://www.cms.gov/manuals/downloads/som107_exhibit_166.pdf 
Supplier of Services   
167  CMS-576, CMS-576A,  www.cms.hhs.gov/cmsforms/ 
Organ Procurement  Organization Application 
and Agreement 
168   Organ Procurement  http://www.cms.gov/manuals/downloads/som107_exhibit_168.pdf 
Organization Report   
Form   
169  United Network for  http://optn.org/members/ 
Organ Sharing Members 
170   Model Letter:  Organ  http://www.cms.gov/manuals/downloads/som107_exhibit_170.pdf 
Procurement   
Organization Denial - 
Failure to Meet 
Requirements  
171   Model Letter: Organ  http://www.cms.gov/manuals/downloads/som107_exhibit_171.pdf 
Procurement   
Organization Denial - 
Competing Applications 
172   Model Letter: Organ  http://www.cms.gov/manuals/downloads/som107_exhibit_172.pdf 
Procurement   
Organization Approval 
173   Model Letter: Organ  http://www.cms.gov/manuals/downloads/som107_exhibit_173.pdf 
Procurement   
Organization Notice of 
Termination 
174   Model Letter: Organ  http://www.cms.gov/manuals/downloads/som107_exhibit_174.pdf 
Procurement   
Organization Notice to 
Public and State 
Medicaid/Medicare 
Agencies 
175   Model Letter: Organ  http://www.cms.gov/manuals/downloads/som107_exhibit_175.pdf 
Procurement   
Organization Notice to 
Bordering OPOs 
176   Model Letter: Organ  http://www.cms.gov/manuals/downloads/som107_exhibit_176.pdf 
Procurement   
Organization Corrective 
Action Notice 
177   Attestation Statement for  http://www.cms.gov/manuals/downloads/som107_exhibit_177.pdf 
Federally Qualified   
Health Centers 
178   Federally Qualified  delete 
Health Center Crucial 
Data Extract  179   Information on Medicare  http://www.cms.gov/manuals/downloads/som107_exhibit_179.pdf 
Participation/Federally   
Qualified Health Centers 
180   Notice to Accredited  http://www.cms.gov/manuals/downloads/som107_exhibit_180.pdf 
Psychiatric Hospital of    
Involuntary Termination 
181   Notice to Hospital  http://www.cms.gov/manuals/downloads/som107_exhibit_181.pdf 
Provider of Involuntary   
Termination 
182   Notice of Termination to  http://www.cms.gov/manuals/downloads/som107_exhibit_182.pdf 
Supplier   
183   Model Public Notice of  http://www.cms.gov/manuals/downloads/som107_exhibit_183.pdf 
Medicare Termination of   
Hospital Provider 
Agreement 
184  Advertising Order, SF- delete 
1143, and Public 
Voucher for Advertising, 
SF-1144  
185   Model Telegram-Notice  http://www.cms.gov/manuals/downloads/som107_exhibit_185.pdf 
of Termination to a   
Medicaid ICF/IID 
Following "Look 
Behind" Survey: 
Immediate and Serious 
Threat to Patient Health 
and Safety 
186   Sample Memorandum  delete 
Disallowance Claims for 
Federal Payments, (Used 
in Look-Behind 
Disapprovals) 
187  Notification to  http://www.cms.gov/manuals/downloads/som107_exhibit_187.pdf 
Previously Approved   
Supplier of a Pending 
Termination 
188   Notification: Voluntary  http://www.cms.gov/manuals/downloads/som107_exhibit_188.pdf 
Termination of Provider   
Agreement Approved 
189   Notification: Approval of  http://www.cms.gov/manuals/downloads/som107_exhibit_189.pdf 
Voluntary Termination of  
a Supplier 
190   Notification to Provider  http://www.cms.gov/manuals/downloads/som107_exhibit_190.pdf  That Has Ceased or Is   
Ceasing Operations 
191   Notification to Supplier  http://www.cms.gov/manuals/downloads/som107_exhibit_191.pdf 
That Has Ceased or is   
Ceasing Operations 
192   Acknowledgment of  http://www.cms.gov/manuals/downloads/som107_exhibit_192.pdf 
Request for Hearing   
193  Model Letter Informing  Deleted 
PPS-Excluded 
Hospital/Units that 
Reverification has Been 
Approved 
194   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_194.pdf 
Announcing to Deemed,   
Accredited 
Provider/Supplier 
Compliance with all 
Surveyed Medicare 
Conditions of 
Participation, Coverage 
or Certification after a 
Sample Validation or 
Substantial Allegation 
Survey 
195   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_195.pdf 
Announcing to Deemed,   
Accredited 
Provider/Supplier that the 
Facility Does Not 
Comply with all the 
Conditions of 
Participation, Coverage 
or Certification and That 
There is Immediate and 
Serious Threat to Patient 
Health and Safety 
196   Model Letter  http://www.cms.gov/Regulations-and-
Announcing to Deemed  Guidance/Guidance/Manuals/downloads/som107_exhibit_196.pdf 
Status Provider/Supplier 
after a Validation Survey 
that it does not Comply 
with all Medicare 
Conditions 
197   Notice to Accredited  http://www.cms.gov/manuals/downloads/som107_exhibit_197.pdf 
Hospital Announcing    Approval of Plan of 
Correction and 
Completion Schedule 
198   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_198.pdf 
Announcing Compliance   
with all Conditions of 
Participation after the 
Effectuation of an 
Acceptable Plan of 
Correction 
199   Model Letter  http://www.cms.gov/Regulations-and-
Announcing to Deemed  Guidance/Guidance/Manuals/downloads/som107_exhibit_199.pdf 
Status Provider/Supplier 
after a Substantial 
Allegation Survey that it 
will Undergo a Full 
Survey 
200   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_200.pdf 
Acknowledging   
Complaint Alleging 
Noncompliance with 42 
CFR 489.24 and/or the 
Related Requirements of 
42 CFR 489.20 
Investigation not 
warranted 
201   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_201.pdf 
Acknowledging   
Complaint Alleging 
Noncompliance with 42 
CFR 489.24 and/or the 
Related Requirements of 
42 CFR 489.20 
Investigation warranted 
202   Model Letter Requesting  http://www.cms.gov/manuals/downloads/som107_exhibit_202.pdf 
QIO Review of a   
Possible Violation of 42 
CFR 489.24 
203   Model Letter Following  http://www.cms.gov/manuals/downloads/som107_exhibit_203.pdf 
Investigation Into   
Alleged Violation of 42   
CFR 489.24 And/Or The 
Related Requirements of 
42 CFR 489.20 Facility 
In Compliance  204   Model Letter For  http://www.cms.gov/manuals/downloads/som107_exhibit_204.pdf 
Violation of 42 CFR   
489.24: Preliminary 
Determination Letter 
(Immediate and Serious 
Threat) 
205   Model Letter For  http://www.cms.gov/manuals/downloads/som107_exhibit_205.pdf 
Violation of 42 CFR   
489.24 And/Or The 
Related Requirements of 
42 CFR 489.20: 
Preliminary 
Determination Letter (90 
Day Termination Track) 
206   Model Letter To  http://www.cms.gov/manuals/downloads/som107_exhibit_206.pdf 
Complainant Following   
Investigation of Alleged 
Violation of 42 CFR 
489.24 And/Or The 
Related Requirement of 
42 CFR 489.20 
Complaint Not 
Substantiated 
207   Model Letter To  http://www.cms.gov/manuals/downloads/som107_exhibit_207.pdf 
Complainant Following   
Investigation of Alleged 
Violation of 42 CFR 
489.24 And/Or The 
Related Requirements of 
42 CFR 489.20 
Complaint Substantiated 
208   Model Letter For  http://www.cms.gov/manuals/downloads/som107_exhibit_208.pdf 
Referring Violation of 42   
CFR 489.24 To The 
Office of Inspector 
General 
209   Model Letter For  http://www.cms.gov/manuals/downloads/som107_exhibit_209.pdf 
Referring Violation of 42   
CFR 489.24 To The 
Regional Office for Civil 
Rights 
210   Model Letter For Past  http://www.cms.gov/manuals/downloads/som107_exhibit_210.pdf 
Violation of 42 CFR   
489.24 And/Or The 
Related Requirements of 
42 CFR 489.20 No  Termination 
211   Model Letter For  http://www.cms.gov/manuals/downloads/som107_exhibit_211.pdf 
Violation of 42 CFR   
489.24 And/Or The 
Related Provisions of 42 
CFR 489.20 Notice of 
Termination 
212   Model Letter Requesting  http://www.cms.gov/manuals/downloads/som107_exhibit_212.pdf 
QIO Review of A   
Confirmed Violation of 
42 CFR 489.24 For 
Purpose of Assessing 
Civil Monetary Penalties 
(CMPs) Or Excluding 
Physicians 
213   State Test Administration delete 
Plan 
214   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_214.pdf 
Announcing to State   
Survey Agency the 
Requirements for 
Administering the Long 
Term Care Surveyor 
Minimum Qualifications 
Test (SMQT) 
215   Notification to  delete 
Provider/Supplier 
Warning of Possible 
Termination--Failure to 
Disclose Financial 
Interest and Ownership 
Information  
216   Report on Initial Survey  http://www.cms.gov/manuals/downloads/som107_exhibit_216.pdf 
Activity 
217   Aging Report on Pending http://www.cms.gov/manuals/downloads/som107_exhibit_217.pdf 
Initial Survey Activity 
218   Prerelease Notification  delete 
Document 
219   Model Audit  http://www.cms.gov/manuals/downloads/som107_exhibit_219.pdf 
Disallowance Letter -   
Title XVIII 
220   Model Audit  http://www.cms.gov/manuals/downloads/som107_exhibit_220.pdf 
Disallowance Letter -    Title XIX 
221   Example of Regular  http://www.cms.gov/manuals/downloads/som107_exhibit_221.pdf 
Disallowance Letter 
222   Audit Clearance  http://www.cms.gov/manuals/downloads/som107_exhibit_222.pdf 
Document 
223   Model Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_223.pdf 
Announcing to Deemed,   
Accredited   
Provider/Supplier After a 
Sample Validation 
Survey That It Does Not 
Comply with all 
Conditions of 
Participation/Conditions 
for Coverage 
224   Notice to Accredited  http://www.cms.gov/manuals/downloads/som107_exhibit_224.pdf 
Laboratory  Announcing   
Approval of Plan of 
Correction and 
Completion Schedule for 
Correcting Deficiencies 
225   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_225.pdf 
Announcing Compliance   
With Applicable CLIA 
Conditions After A 
Sample Validation or 
Substantial Allegation of 
Noncompliance Survey 
226   Accredited Laboratory  delete 
Allegation(s) Report, 
CMS-2878A 
227   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_227.pdf 
Announcing to the CLIA-  
Exempt Laboratory After 
a Sample Validation or 
Substantial Allegation of 
Noncompliance Survey 
That It Does Not Comply 
With Application 
Program Requirements 
228   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_228.pdf 
Announcing to the State   
Laboratory Program, 
After A Sample 
Validation or Substantial  Allegation of 
Noncompliance Survey 
That a CLIA-Exempt 
Laboratory Does Not 
Comply With Applicable 
Program Requirements 
229   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_229.pdf 
Announcing to the CLIA-  
Exempt Laboratory, That 
CMS Will Seek a 
Temporary Injunction or 
Restraining Order 
230   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_230.pdf 
Announcing to the State   
Laboratory Licensure 
Program That CMS Will 
Seek a Temporary 
Injunction or Restraining 
Order to Enjoin 
Continued Operation 
231   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_231.pdf 
Announcing to the CLIA-  
Exempt Laboratory, 
After a Sample 
Validation or Substantial 
Allegation of 
Noncompliance Survey 
That It Does Not Comply 
With Applicable Program 
Requirements (No 
Immediate Jeopardy) 
232  Model Letter: Announcing https://www.cms.gov/Regulations-and-
to the State Laboratory  Guidance/Guidance/Manuals/downloads/som107_exhibit_232.pdf 
Program, After a Sample 
Validation or Substantial 
Allegation of 
Noncompliance Survey, 
That a CLIA-Exempt 
Laboratory Does Not 
Comply With Applicable 
Program Requirements 
(No Immediate Jeopardy)  
 
233   Fraud and Abuse - Office  delete 
of Inspector General, 
Office of Investigations 
Field Officer  234   CLIA Notice of  delete 
Noncompliance and 
Proposed Alternative 
Sanction(s) - No 
Immediate Jeopardy 
235   Notice of Suspension or  delete 
Limitation of the CLIA 
Certification - Immediate 
Jeopardy. 
236   Notice of Imposition of  delete 
Sanction(s): 
Acknowledgment of 
Information Received 
237   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_237.pdf 
Announcing to an   
Accredited Laboratory 
After a Sample 
Validation Survey or a 
Substantial Allegation of 
Noncompliance Survey 
That It Does Not Comply 
with all CLIA Conditions 
and That There Exists, 
Immediate Jeopardy to 
the Health and Safety of 
Individuals or That of the 
General Public 
238   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_238.pdf 
Announcing to an   
Accredited Laboratory 
After a Sample 
Validation Survey That 
the Laboratory Does Not 
Comply With All the 
CLIA Conditions- No 
Immediate Jeopardy 
239  Clinical Laboratory  delete 
Improvement 
Amendments (CLIA) 
Alternate Quality 
Assessment Survey, 
CMS-667 
240   Notice of Proposed  delete 
Limitation of the CLIA 
Certification and 
Suspension of Medicare  Payments When a 
Laboratory Has Failed to 
Participate Successfully 
in a Proficiency Testing 
Program 
241   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_241.pdf 
Announcing to   
Accredited Laboratory 
After a Substantial 
Allegation of 
Noncompliance Survey 
That the Laboratory Does 
Not Comply With All 
CLIA Conditions 
(Complaint) 
242  Request for Validation of  https://www.cms.gov/Medicare/CMS-Forms/CMS-
Accreditation Survey for  Forms/Downloads/CMS2802A.pdf 
Laboratories, CMS-  
2802A 
 
243   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_243.pdf 
Announcing to a CLIA   
Exempt Laboratory That 
It Is In Compliance With 
the CLIA Conditions 
After a Sample 
Validation or Substantial 
Allegation of 
Noncompliance Survey 
244   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_244.pdf 
Announcing to the State   
Laboratory Program, 
That A CLIA-Exempt 
Laboratory is in 
Compliance with the 
CLIA Conditions After a 
Sample Validation or 
Substantial Allegation of 
Noncompliance Survey 
245   CLIA Adverse Action  delete 
Extract, CMS-462A/B 
246   Model Letter: Regional  delete 
Office Notifying a State-
Operated Laboratory of 
Cited Deficiencies and 
Requesting a Plan of  Correction 
247   Notice of (Limitation or)  delete 
Revocation of a 
Laboratory's CLIA 
Certificate - No 
Immediate Jeopardy 
248   Notice of Proposed  delete 
Limitation, Suspension, 
or Revocation of the 
CLIA Certificate; 
Opportunity for a 
Hearing - No Immediate 
Jeopardy 
249   Model Application Letter  
http://www.cms.gov/manuals/downloads/som107_exhibit_249.pd
Notifying Transplant 
f 
Hospital that a complete 
 
Medicare General 
Enrollment Health Care 
CMS-855A need to be 
completed 
250   Model Application Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_250.pdf 
to Transplant Hospital   
Requiring Partial 
Medicare General 
Enrollment Health Care 
CMS-855A 
251   Model Letter for First  http://www.cms.gov/manuals/downloads/som107_exhibit_251.pdf 
Rejection of a Request   
for Medicare approval of 
one or more Organ 
Transplant Programs 
252   Model Reminder Letter  http://www.cms.gov/manuals/downloads/som107_exhibit_252.pdf 
for First Rejection of a   
Request for Medicare 
approval of one or more 
Organ Transplant 
Programs 
253   Organ Transplant  http://www.cms.gov/manuals/downloads/som107_exhibit_253.pdf 
Hospital Worksheet   
254   Model Letter:  http://www.cms.gov/manuals/downloads/som107_exhibit_254.pdf 
Notification to Applicant 
that Medicare General 
Enrollment Health Care 
Provider/Supplier 
Application Has Been  Denied 
255A   Notice to Accredited  http://www.cms.gov/manuals/downloads/som107_exhibit_255A.pdf 
Laboratory  Announcing   
Approval of Plan of   
Correction and 
Completion Schedule for 
Correcting Deficiencies 
256  Form CMS-855 -  http://www.cms.gov/cmsforms/ 
Medicare and Other   
Federal Health Care 
Program General 
Enrollment Health Care 
Provider/Supplier 
Application 
257   Form CMS-855C -  http://www.cms.gov/cmsforms/ 
Medicare and Other   
Federal Health Care 
Program Change of 
Information Health Care 
Provider/Supplier 
Application 
258   Form CMS-855R -  http://www.cms.gov/cmsforms/ 
Medicare and Other   
Federal Health Care 
Program Individual 
Reassignment of Benefits 
Health Care 
Provider/Supplier 
Application 
259   Minimum Data Set  http://www.cms.gov/manuals/downloads/som107_exhibit_259.pdf 
Automation   
Contract/Agreement 
Approval RO Checklist 
260   MDS Key Field  http://www.cms.gov/manuals/downloads/som107_exhibit_260.pdf 
Correction Form   
261   Privacy Act Statement -  http://www.cms.gov/manuals/downloads/som107_exhibit_261.pdf 
Health Care Records   
262   Overview of MDS  http://www.cms.gov/manuals/downloads/som107_exhibit_262.pdf 
Version 2.0 Correction   
Policy for Locked 
Records 
263   Submission Timeframe  http://www.cms.gov/manuals/downloads/som107_exhibit_263.pdf 
for MDS Records     264  Resident Census and  http://www.cms.gov/cmsforms/ 
Conditions of Residents -   
CMS-672  
265  Roster/Sample Matrix -  http://www.cms.gov/cmsforms/ 
CMS-802   
266  Roster/Sample Matrix  http://www.cms.gov/manuals/downloads/som107_exhibit_266.pdf 
Provider Instructions   
(Use with Form CMS-
802) - CMS-802P 
267   Roster/Sample Matrix  http://www.cms.gov/manuals/downloads/som107_exhibit_267.pdf 
Instructions for   
Surveyors (Use with 
Form CMS-802) - CMS-
802S 
268   Facility Characteristics  http://www.cms.gov/manuals/downloads/som107_exhibit_268.pdf 
 
269   Facility Quality  http://www.cms.gov/manuals/downloads/som107_exhibit_269.pdf 
Measure/Indicator Report  
270   Resident Level Quality  http://www.cms.gov/manuals/downloads/som107_exhibit_270.pdf 
Measure/Indicator   
Report:  Chronic Care 
Sample 
271   QM/QI Reports  http://www.cms.gov/manuals/downloads/som107_exhibit_271.pdf 
Technical Specifications:   
Version 1.0 
272   Overview of MDS  http://www.cms.gov/manuals/downloads/som107_exhibit_272.pdf 
Submission Record   
273   Correction Policy  http://www.cms.gov/manuals/downloads/som107_exhibit_273.pdf 
Summary Matrix   
274   Definition of Important  http://www.cms.gov/manuals/downloads/som107_exhibit_274.pdf 
Dates in the RAI Process   
275   Attestation Statement for  http://www.cms.gov/manuals/downloads/som107_exhibit_275.pdf 
CMHCs   
276   Health Insurance Benefit  Deleted 
Agreement for CMHCs 
277   Fiscal Intermediary (FI)  http://www.cms.gov/manuals/downloads/som107_exhibit_277.pdf 
Medicare Provider   
Billing Number 
Deactivation Letter Used 
by FI 
278   Model Denial Letter for  http://www.cms.gov/manuals/downloads/som107_exhibit_278.pdf  CMHC Applicants - State  
Restrictions on Screening 
279   Model Letter - Notice of  http://www.cms.gov/manuals/downloads/som107_exhibit_279.pdf 
Findings for   
Noncompliance for 
CMHCs 
280   Model Letter - Notice of  http://www.cms.gov/manuals/downloads/som107_exhibit_280.pdf 
Termination of Provider   
Agreement for CMHCs 
281   Model Letter - CMHC  http://www.cms.gov/manuals/downloads/som107_exhibit_281.pdf 
That Has Ceased   
Operation 
282   Model Letter -  http://www.cms.gov/manuals/downloads/som107_exhibit_282.pdf 
Participation in Medicare   
as a CMHC Providing 
Partial Hospitalization 
Services (Including 
Threshold and Service 
Requirements) 
283   Model Letter - Notice of  http://www.cms.gov/manuals/downloads/som107_exhibit_283.pdf 
Failure to Meet   
Threshold and Service 
Requirements, CMHCs 
284   Model Denial Letter - To  http://www.cms.gov/manuals/downloads/som107_exhibit_284.pdf 
a Home Health Agency   
(HHA) That Requested a 
Branch Office 
285   Worksheet for OBQM &  http://www.cms.gov/manuals/downloads/som107_exhibit_285.pdf 
OBQI Reports  Pre-  
Survey Process and 
Sample Selection 
286   Hospital/CAH Medicare  http://www.cms.gov/manuals/downloads/som107_exhibit_286.pdf 
Database Worksheet   
287   Authorization by  http://www.cms.gov/Regulations-and-
Deemed  Guidance/Guidance/Manuals/downloads/som107_exhibit_287.pdf 
Provider/Supplier   
Selected for Validation 
Survey 
288   Surveyor Worksheet For  http://www.cms.gov/manuals/downloads/som107_exhibit_288.pdf 
Swing-Beds    
289  Model Reciprocal  http://www.cms.gov/manuals/downloads/som107_exhibit_289.pdf 
Agreement Between   
States for Survey and  Certification of Home 
Health Agencies and/or 
Hospices 
290  Model letter to HHAs  http://www.cms.gov/manuals/downloads/som107_exhibit_290.pdf 
Assigning Branch   
Identification Numbers 
291  Model Notice to  http://www.cms.gov/manuals/downloads/som107_exhibit_290.pdf 
Hospital/CAH of   
Collection of Data by the 
State Agency 
292  INSTRUCTIONS FOR  http://www.cms.gov/manuals/downloads/som107_exhibit_292.pdf 
COMPLETING THE   
DATA USE 
AGREEMENT (DUA) 
FORM CMS-R-0235 
293  CMS DUA: ACTS SOR  http://www.cms.gov/manuals/downloads/som107_exhibit_293.pdf 
Attachment - P&A   
294  DUA Multi-Signature  http://www.cms.gov/manuals/downloads/som107_exhibit_294.pdf 
Addendum   
 
351  Ambulatory Surgical  http://www.cms.gov/manuals/downloads/som107_exhibit_351.pdf 
Center Infection Control   
Surveyor Worksheet 
352  Notice to a  http://www.cms.gov/manuals/downloads/som107_exhibit_352.pdf 
Provider/supplier that 
Agreement was not 
Accepted 
353  Report of a Hospital  http://www.cms.gov/Regulations-and-
Death Associated with  Guidance/Guidance/Manuals/downloads/som107_exhibit_353.pdf 
Restraint or Seclusion 
(Form CMS-10455) 
354  Model Letter To Involved  http://www.cms.gov/Regulations-and-
Resident, Resident  Guidance/Guidance/Manuals/downloads/som107_exhibit_354.pdf 
Representative And/Or 
State Ombudsman  
Opportunity To Provide 
Written Comment 
(Independent Informal 
Dispute Resolution (Idr) 
Has Been Requested) 
355  Probes and Procedures for  http://www.cms.gov/Regulations-and-
Appendix J, Part II-  Guidance/Guidance/Manuals/downloads/som107_exhibit_355.pdf 
Interpretive Guidelines- Responsibilities of 
Intermediate Care 
Facilities for Individuals 
with Intellectual 
Disabilities 
356  Critical Access Hospital  http://www.cms.gov/Regulations-and-
(CAH) Recertification  Guidance/Guidance/Manuals/downloads/som107_exhibit_356.pdf 
Checklist:  Rural and 
Distance or Necessary 
Provider Verification 
 
358  Sample Form for Facility 
https://www.cms.gov/files/document/som107exhibit358.pdf 
Reported Incidents   
 
 
 
359  Follow-up Investigation 
https://www.cms.gov/files/document/som107exhibit359.pdf 
Report