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pdfDEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
CMS-417
I. Identifying
Information
Name of Hospice:
Street Address of Hospice:
Request to Establish Eligibility in Medicare?
City & State:
Yes
No
County:
II. AO
Information
(Check One)
(PH6 1)
III. Hospice
Affiliation
(Check One)
(PH7)
Region:
(PH3)
Accreditation Commission for Healthcare
(ACHC)
Community Health Accreditation Partner
(CHAP)
(PH1)
Zip Code:
Telephone Number:
(PH4)
Related Facility CCN:
Hospice’s CCN:
(PH5)
The Joint Commission (TJC)
Non Accredited
Hospital
Home Health Agency (HHA)
Skilled Nursing Facility (SNF)
Free Standing Hospice
(PH6)
(PH2)
Start Date of Last Survey:
End Date of Last Survey:
Intermediate Care Facility (ICF)
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
CMS-417
Non-Profit
IV. Type of
For Profit/Privately Owned
Government Owned/Operated
Control
(Check One)
1. Church
4. Individual
8. State
3. Other
6. Corporation
10. City
2. Private
5. Partnership
7. Other
(PH8)
Core Hospice
Services
V.
How
Hospice
Services
Are
Provided
1. Physician
Services
(PH9)
How Services Provided
(Select all that apply)
1. By hospice staff
9. County
11. City-County
12. Non-profit Govt. owned and/or
operated Hospice
13. Other type of Govt owned and/or
operated Hospice
Name & Address of Other
Certified Hospice or Outside
Contractor (if any)
CCN of Other Certified
Hospice or Supplier
Number of Outside
Contractor (if any)
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
CMS-417
V.
How
Hospice
Services
Are
Provided
(continued)
Note: Services
marked with “(PH9)”
are core hospice
services.
Core Hospice
Services
2. Nursing
Services
(PH9)
3. Medical
Social
Services
(PH9)
4. Counseling
Services
(PH9)
How Services Provided
(Select all that apply)
1. By hospice staff
Name & Address of Other
Certified Hospice or Outside
Contractor (if any)
CCN of Other Certified
Hospice or Supplier
Number of Outside
Contractor (if any)
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
V.
How
Hospice
Services
Are
Provided
(continued)
Note: Services that
are marked as
“(PH10)” represent
non-core hospice
services.
Non-Core
Hospice Services
5. Physical
Therapy
Services
(PH10)
6. Occupational
Therapy
Services
(PH10)
7. Speech
Language
Pathology
Services
(PH10)
FORM APPROVED
OMB No. 0938-0313
How Services Provided
(Select all that apply)
1. By hospice staff
Name & Address of Other
Certified Hospice or Outside
Contractor (if any)
CCN of Other Certified
Hospice or Supplier
Number of Outside
Contractor (if any)
By contract with an outside party
2. By arrangement with another certified
hospice
3. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
CMS-417
V.
How
Hospice
Services
Are
Provided
(continued)
Non-Core
Hospice Service
8. Hospice
Aide
Services
(PH10)
9. Homemaker
Services
(PH10)
10. Medical
Supplies
(PH10)
How Services Provided
(Select all that apply)
1. By hospice staff
Name & Address of Other
Certified Hospice or Outside
Contractor (if any)
CCN of Other Certified
Hospice or Supplier
Number of Outside
Contractor (if any)
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
V.
How
Hospice
Services
Are
Provided
(continued)
Other Hospice
Service
FORM APPROVED
OMB No. 0938-0313
How Services Provided
(Select all that apply)
11. Short Term
1. By staff
(Including respite
care & general
inpatient care (GIP)
3. By arrangement with another certified
hospice
Inpatient Care
(PH10)
12. Other Hospice
Service #1:
(Specify)
(PH10)
12. Other Hospice
Service #2:
(Specify:)
(PH10)
Name & Address of Other
Certified Hospice or Outside
Contractor (if any)
CCN of Other Certified
Hospice or Supplier
Number of Outside
Contractor (if any)
2. By contract with an outside party
4. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
1. By hospice staff
2. By contract with an outside party
3. By arrangement with another certified
hospice
4. Not applicable
CMS-417 / OMB Approval Expires XX/XX/20XX
Page 6 of 17
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
CMS-417
VI. Full-Time Equivalents
for Employees and Volunteers
Job Categories
Note #1: See the Instructions section
(at the end of this form) for guidance on
Physicians (M.D. or D.O.)
how to calculate the full-time
equivalents (FTEs) for each job category
of hospice employees and hospice
volunteers.
Registered Nurses (R.N.s)
Note #2: The FTE numbers entered in
columns 3 & 4 must have 3 decimal
points (Example: 3.000; 2.750; 7.500)
Hospice
Employee
Full-Time
Equivalents
(FTEs)
(PH11)
(PH12)
Licenses Practical or Vocational Nurses (LPN or LVN)
(PH13)
Homemakers
(PH15)
Medical Social Workers
(PH14)
Hospice Aides
(PH16)
Others
(PH18)
Counselors
TOTAL FTEs
CMS-417 / OMB Approval Expires XX/XX/20XX
Hospice
Volunteer
Full-Time
Equivalents
(FTEs)
(PH17)
(PH19)
0.000 0.000
Page 7 of 17
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
ATTESTATION STATEMENT
Whoever knowingly or willfully makes or causes to be made a false statement or representation on this form
may be prosecuted under applicable Federal or State laws. In addition, knowingly and willfully failing to fully
and accurately disclose the information requested may result in denial of a request to participate, or where the
entity already participates, a termination of its agreement or contract with the State agency or the Secretary as
appropriate.
Printed Name of Hospice Representative:
Signature of Hospice Representative:
CMS-417 / OMB Approval Expires XX/XX/20XX
Title of Hospice Representative:
Date Form Completed:
Page 8 of 17
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0313 (Expires XX/XX/202X). This is a mandatory
information collection. The time required to complete this information collection is estimated to average 45 minutes per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance
Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please
contact QSOG_Hospice@cms.hhs.gov.
CMS-417 / OMB Approval Expires XX/XX/20XX
Page 9 of 17
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
INSTRUCTIONS
This form serves two purposes. First, it provides basic information about the Hospice which is necessary for the State to properly schedule a survey.
Second, it provides a data-base necessary for responding to questions frequently asked by Congress, Federal agencies, and interested members of the
public.
Submission of this form will initiate the process of obtaining a decision as to whether the Conditions are met.
Answer all questions as of the current date.
Complete and return this form to your State Agency (found at https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/downloads/state_agency_contacts.pdf), and retain a copy for your files.
Detailed instructions are given for questions other than those considered self-explanatory.
Item I: Identifying Information
Request to establish eligibility in:
• If the hospice is requesting initial certification for the Medicare program, select the “Yes”.
• If the hospice already participates in the Medicare program and is seeking re-certification, select “No”.
CMS certification number (CCN):
• Insert the hospice program’s six-digit CMS Certification Number (CCN).
• Leave blank if the hospice is requesting initial certification and has not yet been assigned a CCN number.
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
INSTRUCTIONS
(continued)
Region:
• Leave blank. The Centers for Medicare & Medicaid Services (CMS) Location (formerly named “CMS Regional Office”) will complete.
Related Certification Number:
•
If the hospice is affiliated with any other Medicare provider(s) or supplier(s), insert the related facility’s six digit CMS Certification
Number (CCN).
Item III: Hospice Affiliations
•
•
The purpose of this question is to find out whether the hospice is located in, associated with, or part of another healthcare facility.
Please select the option that best describes the type of healthcare facility in which your hospice is located, or with which your
hospice is associated, or that your hospice is part of.
Examples:
o If you hospice is physically located in, associated with or part of a hospital or hospital system that provides hospice
services, select “Hospital”.
o If your hospice is physically located in, associated with, or part of a nursing home, select “Skilled Nursing Facility”.
o If your hospice is physically located in, associated with, or part of an Intermediate Care Facility (ICF), select “Intermediate
Care Facility”.
o If you are a Home Health Agency that provides hospice services, select “Home Health Agency”.
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
INSTRUCTIONS
(continued)
o If your hospice is not located within or part of another healthcare facility, has its own facility, and provides either inpatient
hospice care, outpatient hospice care, or both, select “Freestanding Hospice”.
Item IV: Type of Control
•
•
•
The purpose of this section is to find out what type of legal entity owns and/or operates the hospice.
In this section, the following three (3) general categories of legal ownership/operation status categories listed:
1. Non-Profit
2. For Profit/Privately Owned
3. Government Owned/Operated
Under the three (3) general categories, more specific types of legal ownership/operation status types are listed, as shown below.
Non-Profit
1. Church
2. Private
3. Other
•
For Profit/Privately Owned
4. Individual
5. Partnership
6. Corporation
7. Other
Government Owned/Operated
8. State
9. County
10. City
11. County-City
12. Non-profit Govt. owned and/or operated Hospice
13. Other type of Govt owned and/or operated Hospice
Check one option under one of the three (3) categories that best describes your hospice’s legal ownership/operation status.
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
Item V. Type of Hospice Services Provided
INSTRUCTIONS
(continued)
Column 1: Contains a list of services that are typically provided by hospices.
NOTE: Row 11 – Short term inpatient care includes both general inpatient care (GIP) and respite care.
Column 2: How Hospice Services Are Provided:
•
•
•
The available responses include:
1.
2.
3.
4.
By hospice staff (or “By Hospice” as applicable)
By contract with an outside party
By arrangement with another certified hospice
Not Applicable
For each service listed, select ALL responses that apply to your hospice.
Examples:
o You may select ALL responses that apply to how the service is provided.
o If the service is provided only by the hospice or hospice staff, you should select “1. By hospice staff” or “1. By hospice”.
o If the hospice contracts with an outside party to provide this service, you should select “2. By contract with an outside
party”.
o If the hospice has an arrangement with another certified hospice to provide this service, you should select “3. By
arrangement with another certified hospice”.
CMS-417 / OMB Approval Expires XX/XX/20XX
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
INSTRUCTIONS
(continued)
o If the service if provided by the hospice or hospice staff and the hospice also contracts with an outside party to provide this
service, you should select both “1. By hospice staff” or “1. By hospice” and “4. By contract with an outside party”.
o If the service if provided by the hospice or hospice staff and the hospice also has an arrangement with another certified
hospice to provide this service, you should select both “1. By hospice staff” or “1. By hospice” and “5. By arrangement
with another certified hospice”.
o If the hospice does not provide this service and does not use any outside source to provide this service, you should select
“6. Not applicable”.
NOTE: Response #1 for some services will be “1. By hospice staff” but for other services will be “1. By hospice” as
applicable.
Column 3: Name & Address of Other Certified Hospice of Outside Contractor
•
If the service is provided by another certified hospice or an outside contractor or service supplier, provide the name and address
of this hospice, or outside contractor, or service supplier.
Column 4: CCN/ Supplier Number of Other Certified Hospice, or Outside Contractor
•
If service is provided by another certified hospice or an outside contractor or service supplier, provide the CCN or supplier
number for that other certified hospice, outside contractor or service supplier.
CMS-417 / OMB Approval Expires XX/XX/20XX
Page 14 of 17
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
INSTRUCTIONS
(continued)
Item VI. Full Time Equivalents for Employees and Volunteers
Column 2: Contains a list of job types that employees and volunteer may perform at a hospice facility.
Column 3: Full-Time Equivalents (FTEs) For Hospice Employees (Employee FTEs)
•
•
•
Conduct the FTE calculation for each job category listed.
The number of full-time equivalents (FTEs) for all hospice employees in a specific job category is calculated using the total
number of hours for all hospice employees in that job category divided by 2,080 hours per year.
You should do the following when calculating the number of hours worked per year for full and part-time hospice employees in
each job category:
o For full-time employees: Use 2,080 hours as the number of work hours per for each full-time employee.
(40 hours x 52 weeks = 2,080 hours).
o For part time employees that work the entire year: Use the number of hours worked per week multiplied by 52 weeks
per year to calculate the number of hours worked per year.
•
•
o For part-time employee that only work part of the year: Use the number of hours worked per week multiplied by the
actual number of weeks worked per year. (Example: 20 hours per week x 26 weeks per year = 520 hours per year).
The hospice employee FTE values entered should have 3 decimal points. (Example: 3.921. 5.000, 2.250, 7.500)
The form will automatically calculate the total number of employee FTEs.
CMS-417 / OMB Approval Expires XX/XX/20XX
Page 15 of 17
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
INSTRUCTIONS
(continued)
Example of How to Calculate Hospice Employee FTEs:
4,500 (Total number of hours worked per year by employees in the category)
÷ 2,080 hours (number of work hours in a year)
= 2.163 FTEs Number of Employee Physician FTEs
Column 4: Full-Time Equivalents (FTEs) For Hospice Volunteer (Volunteer FTEs)
•
•
•
Conduct the FTE calculation for all volunteers in each job category listed.
The full-time equivalent (FTE) for hospice volunteers in a specific job category is calculated using the total number of hours for
all hospice volunteers in that job category divided by 2,080 hours per year.
You should do the following when calculating the number of hours worked per year for full and part-time hospice volunteers in
each job category:
o For full-time volunteers: Use 2,080 hours as the number of work hours per for each full-time employee.
(40 hours x 52 weeks= 2,080 hours).
o For part-time volunteers that work the entire year: Use the number of hours worked per week multiplied by 52 weeks
per year to calculate the number of hours worked per year.
•
o For part-time volunteers that only work part of the year: Use the number of hours worked per week multiplied by the
actual number of weeks worked per year. (Example: 20 hours per week x 26 weeks per year = 520 hours per year).
The hospice volunteer FTE values entered should have 3 decimal points. (Example: 3.921. 5.000, 2.250, 7.500)
CMS-417 / OMB Approval Expires XX/XX/20XX
Page 16 of 17
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED
OMB No. 0938-0313
HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM
(CMS-417)
INSTRUCTIONS
(continued)
Example of How to Calculate Hospice Volunteer FTEs:
2,675 (Total number of hours worked per year by volunteers in the category)
÷ 2,080 hours (number of work hours in a year)
= 1.286 FTEs Number of Employee Physician FTEs
CMS-417 / OMB Approval Expires XX/XX/20XX
Page 17 of 17
| File Type | application/pdf |
| Author | CAROLINE GALLAHER |
| File Modified | 2024-12-02 |
| File Created | 2024-09-26 |