Medicare State Operations Manual

Chapter 9 - Exhibits

Exhibits

(Rev. 242; Issued: 05-29-26)

Exhibit	Description	Download
1A	Model Letter Transmitting Materials to Providers	http://www.cms.gov/manuals/downloads/som107c09_exhibits.pdf
1B-1	Model Letter Transmitting CLIA Application and CMS-855 to Laboratories	http://www.cms.gov/manuals/downloads/som107c09_exhibitstoc.pdf
1C	Model Letter transmitting Forms to Persons Furnishing Portable X-Ray Services	http://www.cms.gov/manuals/downloads/som107_exhibit_001c.pdf
1D	Model Letter Transmitting Materials to Rural Health Clinics	http://www.cms.gov/manuals/downloads/som107_exhibit_001d.pdf
1E	Model Letter to Operational ESRD Facility Requesting Initial Approval	http://www.cms.gov/manuals/downloads/som107_exhibit_001e.pdf
2	Civil Rights Clearance for Medicare Provider Certification	http://www.hhs.gov/ocr/civilrights/resources/providers/medicare_providers/index.html
4	Health Insurance Benefits Agreement, CMS-1561	https://www.cms.gov/medicare/forms-notices/cms-forms-list
4B	Health Insurance Benefits Agreement, CMS-1561A (Rural Health Clinics)	https://www.cms.gov/medicare/forms-notices/cms-forms-list
7	Statement of Deficiencies and Plan of Correction, CMS-2567	https://www.cms.gov/medicare/forms-notices/cms-forms-list
7A	Principles of Documentation	http://www.cms.gov/manuals/downloads/som107_exhibit_007a.pdf

8	Post-Certification Revisit Report, CMS- 2567B	https://www.cms.gov/medicare/forms-notices/cms-forms-list
9	Medicare/Medicaid Certification and Transmittal, CMS- 1539 and User Guide	Located in National Database and Electronic Form is available at: https://www.cms.gov/medicare/health-safety-standards/certification-compliance
12	Survey Report Form (CLIA), CMS-1557	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1557.pdf
14C	Skilled Nursing Facility and Intermediate Care Facility Crucial Data Extract, CMS-519E	Located in the National Surveyor Database
14D	Home Health Agency Survey Report, CMS- 1572	https://www.cms.gov/medicare/forms-notices/cms-forms-list
14H	Outpatient Physical Therapy Survey Report - Crucial Data Extract, CMS-1893E	Delete
14I	ESRD Facility Survey Report- Crucial Data Extract, Form CMS- 3427E (To be used with Part II of Form CMS- 3427)	http://www.cms.gov/manuals/downloads/som107_exhibit_014i.pdf
14J	Rural Health Clinic Survey Report - Crucial Data Extract, CMS-30E	Delete
14K	Intermediate Care Facility - Individuals with Intellectual Disabilities Survey Report-Crucial Data Extract, CMS-3070B(E)	Delete
14L	Ambulatory Surgical Center Report - Crucial Data Extract, CMS-378E	Delete
14M	Therapist in Independent Practice - Crucial Data Extract, CMS-3042E	Delete
14O	Hospice Survey Report - Crucial Data Extract, CMS-449E	Delete

15	Regional Office Request for Additional Information, CMS-1666	Delete
16	Budget Request, Clinical Laboratory Improvement Amendments Program, Form CMS-102	https://scclia.cms.gov/SCCLIA/Default.aspx
21	Request For Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services, CMS-1856	Delete (replaced with CMS-381 Form)
22	Guidance to Distinguish Between the Priorities of Immediate Jeopardy and Non-Immediate Jeopardy-High in Nursing Home Allegations	http://www.cms.gov/manuals/downloads/som107_exhibit_022.pdf
23	ACTS Required Fields	http://www.cms.gov/manuals/downloads/som107_exhibit_023.pdf
26	Model Letter to Rural Health Clinic Ineligible to Participate	http://www.cms.gov/manuals/downloads/som107_exhibit_026.pdf
27	Model Letter to Previously Approved Facility Requesting Approval to Expand or Add a New End Stage Renal Disease (ESRD) Service	http://www.cms.gov/manuals/downloads/som107_exhibit_027.pdf
30	Model Letter to Facility Returning Application not Accompanied by Required Certificate of Need (Where Applicable)	http://www.cms.gov/manuals/downloads/som107_exhibit_030.pdf
31	End Stage Renal Disease Survey Report and Deficiencies Report, CMS-3427	https://www.cms.gov/medicare/forms-notices/cms-forms-list

33	Request for Validation of Accreditation Survey, CMS-2802	https://www.cms.gov/medicare/forms-notices/cms-forms-list
37	Model Letter Announcing Validation Survey Of Deemed Status Provider/Supplier	Delete
41	State Agency's Letter to Medicare SNF Seeking Readmission After Involuntary Termination	http://www.cms.gov/manuals/downloads/som107_exhibit_041.pdf
42	Orientation & Basic Training Program for the Newly Employed Health Facility Surveyor	http://www.cms.gov/manuals/downloads/som107_exhibit_042.pdf
45	State Agency Budget Expenditure Report, CMS-435	https://scclia.cms.gov/SCCLIA/Default.aspx
47	State Agency Budget List of Positions, CMS-1465A of Positions, CMS-1465A	https://scclia.cms.gov/SCCLIA/Default.aspx
52	State Survey Agency Certification Workload Report, CMS-434	https://scclia.cms.gov/SCCLIA/default.aspx
54	State Agency Schedule for Equipment Purchases, CMS-1466	https://scclia.cms.gov/SCCLIA/Default.aspx
56	Request for Certification to Provide OPT/OSP-Initial and Extension Site Requests CMS-381	https://www.cms.gov/medicare/forms-notices/cms-forms-list
57	Model Letter Requesting Identification of Extension Units	Delete
58	Example of a Regular Disallowance Letter	Delete

59	Example of a Deferral Letter	Delete
60	Example of a Disallowance Letter for Amounts Previously Deferred	Delete
61	Example of an Audit Disallowance Letter	Delete
63	List of Documents in Certification Packets (Initial Certifications Include Initial Denials)	http://www.cms.gov/manuals/downloads/som107_exhibit_063.pdf
64	Ambulatory Surgical Center Request for Certification in the Medicare Program, CMS-377	https://www.cms.gov/medicare/forms-notices/cms-forms-list
65	Health Insurance Benefits Agreement, CMS-370	https://www.cms.gov/medicare/forms-notices/cms-forms-list
72	Hospice Request for Certification in the Medicare Program, CMS-417	https://www.cms.gov/medicare/forms-notices/cms-forms-list
73	State Agency Worksheets for Verifying Exclusions from the Prospective Payment System, CMS-437	https://www.cms.gov/medicare/forms-notices/cms-forms-list
74	Survey Team Composition and Workload Report, CMS- 670	https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107_exhibit_074.pdf
75	Medicare/Medicaid Complaint Form, CMS-562	Delete

76	Model Letter to Clinics, Rehabilitation Agencies and Public Health Agencies Initially Applying to Serve as Providers of Outpatient Occupational Therapy Services	Delete
77	Model Letter to Approved Medicare Clinics, Rehabilitation Agencies and Public Health Agencies that Request to Add Outpatient Occupational Therapy Services	Delete
80	Intermediate Care Facility for Individuals with Intellectual Disabilities Survey Report, Form CMS-3070G	https://www.cms.gov/medicare/forms-notices/cms-forms-list
80A	Intermediate Care Facility for Individuals with Intellectual Disabilities Deficiencies Report, Form CMS-3070H	https://www.cms.gov/medicare/forms-notices/cms-forms-list
80B	Individual Observation Worksheet (Intermediate Care Facility for Individuals with Intellectual Disabilities), Form CMS- 3070I	https://www.cms.gov/medicare/forms-notices/cms-forms-list
81	Model Letter Requirements for Swing- Bed Approval in Hospitals	http://www.cms.gov/manuals/downloads/som107_exhibit_081.pdf
82	Model Letter Approval Notification for Swing- Beds in a Hospital	http://www.cms.gov/manuals/downloads/som107_exhibit_082.pdf
83	Model Letter Denial for Swing-Bed Approval In A Hospital	http://www.cms.gov/manuals/downloads/som107_exhibit_083.pdf

85	Long Term Care Facility Application for Medicare and Medicaid, CMS-671	https://www.cms.gov/medicare/forms-notices/cms-forms-list
87	Extended/Partial Extended Survey Worksheet, CMS-673	https://www.cms.gov/medicare/forms-notices/cms-forms-list
88	CMS Nursing Home Survey Forms	Delete, Nursing Home Survey forms are found at https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes.
89	Offsite Survey Preparation Worksheet, CMS-801	Delete, Nursing Home Survey forms are found at https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes.
91	General Observations of the Facility, CMS-803	Delete, refer to above main link.
92	Kitchen/Food Service Observation, CMS-804	Delete, refer to above main link.
93	Resident Review Worksheet, CMS-805	http://www.cms.gov/cmsforms/
94	Quality of Life Assessment, CMS-806 A, B, and C	http://www.cms.gov/cmsforms/
95	Surveyor Notes Worksheet, CMS-807	Delete, Nursing Home Survey forms are found at https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes.
103	Instructions for the Home Health Functional Assessment Instrument (FAI)	Delete
104	Consent For Home Visit, CMS-36	https://www.cms.gov/medicare/forms-notices/cms-forms-list
106	Laboratory Personnel Report (CLIA), CMS-209	https://www.cms.gov/medicare/forms-notices/cms-forms-list
116	Budget Requests, Clinical Laboratory Improvement Amendments Program - CMS-102	https://scclia.cms.gov/SCCLIA/Default.aspx

117	1465A - State Agency Budget List of Position for CLIA Program	https://scclia.cms.gov/SCCLIA/default.aspx
118	1466 – CLIA Program State Agency Schedule for Equipment Purchases	https://scclia.cms.gov/SCCLIA/Default.aspx
119	Planned Workload Report, Clinical Laboratory Improvement Amendments Program, CMS-105	https://scclia.cms.gov/SCCLIA/Default.aspx
122	OMB Circular No. A- 102, Subject: Uniform Administrative Requirements for Grant- In-Aid to State and Local Governments	www.whitehouse.gov/omb/circulars
127	Attestation Statement for Exclusion from PPS for Fiscal Year Beginning: (Date)	http://www.cms.gov/manuals/downloads/som107_exhibit_127.pdf
128	Model Consent for Hospice Home Visit	http://www.cms.gov/manuals/downloads/som107_exhibit_128.pdf
129	Hospice Survey and Deficiencies Report, CMS-643	https://www.cms.gov/medicare/forms-notices/cms-forms-list
130	Model Letter to Entity Seeking Participation in Medicare as a Community Mental Health Center (CMHC) Providing Partial Hospitalization Services	Delete
131	Community Mental Health Center Crucial Data Extract	Delete
132	Public Health Service Act-Section 1916(c)(4)	http://www.cms.gov/manuals/downloads/som107_exhibit_132.pdf

133	Health Insurance Benefit Agreement Delete (duplicative of above)
134	Model Letter Transmitting Requirements to a Hospital Requesting a Change in Status to a Critical Access Hospital (CAH)	http://www.cms.gov/manuals/downloads/som107_exhibit_134.pdf
135	Model Letter Transmitting Swing-Bed Approval Notification in a Critical Access Hospital (CAH)	http://www.cms.gov/manuals/downloads/som107_exhibit_135.pdf
136	Request for Survey of 42 CFR §489.20 and 42 CFR §489.24, Essentials of Provider Agreements: Responsibilities of Medicare Participating Hospitals in Emergency Cases, CMS-1541A	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1541a.pdf
137	Responsibilities of Medicare Participating Hospitals in Emergency Cases Investigation Report, CMS-1541B	https://www.cms.gov/medicare/forms-notices/cms-forms-list
138	EMTALA Physician Review Worksheet	http://www.cms.gov/manuals/downloads/som107_exhibit_138.pdf
139	Model Letter to Provider (Send with Form CMS-2567)(Immediate Jeopardy Does Not Exit)	http://www.cms.gov/manuals/downloads/som107_exhibit_139.pdf
140	Model Letter Notifying Provider of Acceptance of Allegation of Compliance	http://www.cms.gov/manuals/downloads/som107_exhibit_140.pdf
141	Model Letter Notifying Provider of Results of Revisit	http://www.cms.gov/manuals/downloads/som107_exhibit_141.pdf

142	Model Letter to Provider (Imposition of Remedies) (Immediate Jeopardy Does Not Exist)	http://www.cms.gov/manuals/downloads/som107_exhibit_142.pdf
143	Model Letter to Provider (Imposition of Remedies) (Immediate Jeopardy Exists)	http://www.cms.gov/manuals/downloads/som107_exhibit_143.pdf
144	Notice of Imposition of a Civil Money Penalty (Insert to formal notice)	http://www.cms.gov/manuals/downloads/som107_exhibit_144.pdf
145	Notification of Change in the Amount of the Civil Money Penalty	http://www.cms.gov/manuals/downloads/som107_exhibit_145.pdf
146	Notice of Receipt of the Written Request of Waiver of Right to a Hearing	http://www.cms.gov/manuals/downloads/som107_exhibit_146.pdf
147	Notice of Payment Amount Due and Payable	http://www.cms.gov/manuals/downloads/som107_exhibit_147.pdf
147A	Notice Of Payment Amount Due For Placement In Escrow (Iidr Complete Or Not Timely Requested-Facility Is Filing Formal Appeal)	http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_147A.pdf
148	Notification of Deduction of Civil Money Penalty from Money Owing to the Provider	http://www.cms.gov/manuals/downloads/som107_exhibit_148.pdf
149	Model Letter Critical Access Hospital (CAH) Denial for Medicare Participation	http://www.cms.gov/manuals/downloads/som107_exhibit_149.pdf
150	Model Letter Critical Access Hospital (CAH) Approval Notification	http://www.cms.gov/manuals/downloads/som107_exhibit_150.pdf
151	Model Letter Request For A Plan of Correction Following an Initial Critical Access Hospital (CAH) Survey	http://www.cms.gov/manuals/downloads/som107_exhibit_151.pdf

152	Model Letter Critical Access Hospital (CAH) Termination Letter	http://www.cms.gov/manuals/downloads/som107_exhibit_152.pdf
154	Notice of Initial Approval of End - State Renal Disease (ESRD) Facility	http://www.cms.gov/manuals/downloads/som107_exhibit_154.pdf
155	End-Stage Renal Disease (ESRD) Denial Notice	http://www.cms.gov/manuals/downloads/som107_exhibit_155.pdf
156	Provider Tie-In Notice, CMS-2007	https://www.cms.gov/medicare/forms-notices/cms-forms-list
157	Notice - Expansion and/or Additional Service (Approval, Partial Approval or Denial) of ESRD Facility	http://www.cms.gov/manuals/downloads/som107_exhibit_157.pdf
158	Notice - Recertification of ESRD Facility (Not Used for Special Purpose Renal Dialysis Facilities)	http://www.cms.gov/manuals/downloads/som107_exhibit_158.pdf
160	Notice to ESRD Facility - Alternative Sanction for failure to participate with Network Goals and Objectives	http://www.cms.gov/manuals/downloads/som107_exhibit_160.pdf
161	Notice of Interim Approval of CAPD Services	Delete
162	Model Letter Request for a Plan of Correction Following an Initial Survey for Swing-Bed Approval in a Hospital	http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_162.pdf
163	Model Letter Termination Letter for Hospital Swing-Bed Services	http://www.cms.gov/manuals/downloads/som107_exhibit_163.pdf
165	Notice to a Provider that Agreement Was Accepted	http://www.cms.gov/manuals/downloads/som107_exhibit_165.pdf
165a	Notice to a Deemed Provider/ Supplier that Agreement was Accepted	http://www.cms.gov/manuals/downloads/som107_exhibit_165a.pdf

166	Notice of Approval of Supplier of Services	http://www.cms.gov/manuals/downloads/som107_exhibit_166.pdf
167	CMS-576, CMS-576A, Organ Procurement Organization Application and Agreement	https://www.cms.gov/medicare/forms-notices/cms-forms-list
168	Organ Procurement Organization Report Form	Delete
169	United Network for Organ Sharing Members	https://optn.transplant.hrsa.gov/about/search-membership/
170	Model Letter: Organ Procurement Organization Denial - Failure to Meet Requirements	Delete
171	Model Letter: Organ Procurement Organization Denial - Competing Applications	Delete
172	Model Letter: Organ Procurement Organization Approval	Delete
173	Model Letter: Organ Procurement Organization Notice of Termination	Delete
174	Model Letter: Organ Procurement Organization Notice to Public and State Medicaid/Medicare Agencies	Delete
175	Model Letter: Organ Procurement Organization Notice to Bordering OPOs	Delete
176	Model Letter: Organ Procurement Organization Corrective Action Notice	Delete

177	Attestation Statement for Federally Qualified Health Centers	http://www.cms.gov/manuals/downloads/som107_exhibit_177.pdf
179	Information on Medicare Participation/Federally Qualified Health Centers	http://www.cms.gov/manuals/downloads/som107_exhibit_179.pdf
180	Notice to Accredited Psychiatric Hospital of Involuntary Termination	Delete
181	Notice to Hospital Provider of Involuntary Termination	http://www.cms.gov/manuals/downloads/som107_exhibit_181.pdf
182	Notice of Termination to Supplier	http://www.cms.gov/manuals/downloads/som107_exhibit_182.pdf
183	Model Public Notice of Medicare Termination of Hospital Provider Agreement	http://www.cms.gov/manuals/downloads/som107_exhibit_183.pdf
185	Model Telegram-Notice of Termination to a Medicaid ICF/IID Following "Look Behind" Survey: Immediate and Serious Threat to Patient Health and Safety	http://www.cms.gov/manuals/downloads/som107_exhibit_185.pdf
187	Notification to Previously Approved Supplier of a Pending Termination	Delete
188	Notification: Voluntary Termination of Provider Agreement Approved	http://www.cms.gov/manuals/downloads/som107_exhibit_188.pdf
189	Notification: Approval of Voluntary Termination of a Supplier	http://www.cms.gov/manuals/downloads/som107_exhibit_189.pdf
190	Notification to Provider That Has Ceased or Is Ceasing Operations	http://www.cms.gov/manuals/downloads/som107_exhibit_190.pdf

191	Notification to Supplier That Has Ceased or is Ceasing Operations	http://www.cms.gov/manuals/downloads/som107_exhibit_191.pdf
192	Acknowledgment of Request for Hearing	Delete
194	Model Letter 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	http://www.cms.gov/manuals/downloads/som107_exhibit_194.pdf
195	Model Letter 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	http://www.cms.gov/manuals/downloads/som107_exhibit_195.pdf
196	Model Letter Announcing to Deemed Status Provider/Supplier after a Validation Survey that it does not Comply with all Medicare Conditions	http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_196.pdf
197	Notice to Accredited Hospital Announcing Approval of Plan of Correction and Completion Schedule	http://www.cms.gov/manuals/downloads/som107_exhibit_197.pdf
198	Model Letter Announcing Compliance with all Conditions of Participation after the Effectuation of an Acceptable Plan of	http://www.cms.gov/manuals/downloads/som107_exhibit_198.pdf

Correction

199	Model Letter Announcing to Deemed Status Provider/Supplier after a Substantial Allegation Survey that it will Undergo a Full Survey	http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_199.pdf
200	Model Letter Acknowledging Complaint Alleging Noncompliance with 42 CFR 489.24 and/or the Related Requirements of 42 CFR 489.20 Investigation not warranted	http://www.cms.gov/manuals/downloads/som107_exhibit_200.pdf
201	Model Letter Acknowledging Complaint Alleging Noncompliance with 42 CFR 489.24 and/or the Related Requirements of 42 CFR 489.20 Investigation warranted	http://www.cms.gov/manuals/downloads/som107_exhibit_201.pdf
202	Model Letter Requesting QIO Review of a Possible Violation of 42 CFR 489.24	http://www.cms.gov/manuals/downloads/som107_exhibit_202.pdf
203	Model Letter Following Investigation Into Alleged Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20 Facility In Compliance	http://www.cms.gov/manuals/downloads/som107_exhibit_203.pdf
204	Model Letter For Violation of 42 CFR 489.24: Preliminary Determination Letter (Immediate and Serious Threat)	http://www.cms.gov/manuals/downloads/som107_exhibit_204.pdf

205	Model Letter For Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20: Preliminary Determination Letter (90 Day Termination Track)	http://www.cms.gov/manuals/downloads/som107_exhibit_205.pdf
206	Model Letter To Complainant Following Investigation of Alleged Violation of 42 CFR 489.24 And/Or The Related Requirement of 42 CFR 489.20 Complaint Not Substantiated	http://www.cms.gov/manuals/downloads/som107_exhibit_206.pdf
207	Model Letter To Complainant Following Investigation of Alleged Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20 Complaint Substantiated	http://www.cms.gov/manuals/downloads/som107_exhibit_207.pdf
208	Model Letter For Referring Violation of 42 CFR 489.24 To The Office of Inspector General	http://www.cms.gov/manuals/downloads/som107_exhibit_208.pdf
209	Model Letter For Referring Violation of 42 CFR 489.24 To The Regional Office for Civil Rights	http://www.cms.gov/manuals/downloads/som107_exhibit_209.pdf
210	Model Letter For Past Violation of 42 CFR 489.24 And/Or The Related Requirements of 42 CFR 489.20 No Termination	http://www.cms.gov/manuals/downloads/som107_exhibit_210.pdf
211	Model Letter For Violation of 42 CFR 489.24 And/Or The Related Provisions of 42 CFR 489.20 Notice of Termination	http://www.cms.gov/manuals/downloads/som107_exhibit_211.pdf

212	Model Letter Requesting QIO Review of A Confirmed Violation of 42 CFR 489.24 For Purpose of Assessing Civil Monetary Penalties (CMPs) Or Excluding Physicians	http://www.cms.gov/manuals/downloads/som107_exhibit_212.pdf
214	Model Letter Announcing to State Survey Agency the Requirements for Administering the Long Term Care Surveyor Minimum Qualifications Test (SMQT)	http://www.cms.gov/manuals/downloads/som107_exhibit_214.pdf
216	Report on Initial Survey Activity	http://www.cms.gov/manuals/downloads/som107_exhibit_216.pdf
217	Aging Report on Pending Initial Survey Activity	http://www.cms.gov/manuals/downloads/som107_exhibit_217.pdf
219	Model Audit Disallowance Letter - Title XVIII	Delete
220	Model Audit Disallowance Letter - Title XIX	Delete
221	Example of Regular Disallowance Letter	http://www.cms.gov/manuals/downloads/som107_exhibit_221.pdf
222	Audit Clearance Document	http://www.cms.gov/manuals/downloads/som107_exhibit_222.pdf
223	Model Letter Announcing to Deemed, Accredited Provider/Supplier After a Sample Validation Survey That It Does Not Comply with all Conditions of Participation/Conditions for Coverage	http://www.cms.gov/manuals/downloads/som107_exhibit_223.pdf

224 Notice to Accredited Laboratory Announcing Approval of Plan of Correction and Completion Schedule for Correcting Deficiencies http://www.cms.gov/manuals/downloads/som107_exhibit_224.pdf

225 Model Letter: Announcing Compliance With Applicable CLIA Conditions After A Sample Validation or Substantial Allegation of Noncompliance Survey http://www.cms.gov/manuals/downloads/som107_exhibit_225.pdf

227 Model Letter: 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 http://www.cms.gov/manuals/downloads/som107_exhibit_227.pdf

228 Model Letter: 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 http://www.cms.gov/manuals/downloads/som107_exhibit_228.pdf

229 Model Letter: Announcing to the CLIA- Exempt Laboratory, That CMS Will Seek a Temporary Injunction or Restraining Order http://www.cms.gov/manuals/downloads/som107_exhibit_229.pdf

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 the Applicable Program Requirements (No Immediate Jeopardy) Program, After a Sample

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: Announcing to an Accredited Laboratory After a Sample Validation Survey That the Laboratory Does Not Comply With All the CLIA Conditions- No Immediate Jeopardy	http://www.cms.gov/manuals/downloads/som107_exhibit_238.pdf
241	Model Letter: Announcing to Accredited Laboratory After a Substantial Allegation of Noncompliance Survey That the Laboratory Does Not Comply With All CLIA Conditions (Complaint)	http://www.cms.gov/manuals/downloads/som107_exhibit_241.pdf
242	Request for Validation of Accreditation Survey for Laboratories, CMS- 2802A	https://www.cms.gov/medicare/forms-notices/cms-forms-list
243	Model Letter: 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	http://www.cms.gov/manuals/downloads/som107_exhibit_243.pdf
244	Model Letter: 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	http://www.cms.gov/manuals/downloads/som107_exhibit_244.pdf

249	Model Application Letter Notifying Transplant Hospital that a complete Medicare General Enrollment Health Care CMS-855A need to be completed	Delete
250	Model Application Letter to Transplant Hospital Requiring Partial Medicare General Enrollment Health Care CMS-855A	Delete
251	Model Letter for First Rejection of a Request for Medicare approval of one or more Organ Transplant Programs	Delete
252	Model Reminder Letter for First Rejection of a Request for Medicare approval of one or more Organ Transplant Programs	Delete
253	Organ Transplant Hospital Worksheet	Delete
254	Model Letter: Notification to Applicant that Medicare General Enrollment Health Care Provider/Supplier Application Has Been Denied	Delete, available via national surveyor database.
255A	Notice to Accredited Laboratory Announcing Approval of Plan of Correction and Completion Schedule for Correcting Deficiencies	http://www.cms.gov/manuals/downloads/som107_exhibit_255A.pdf

256	Form CMS-855 - Medicare and Other Federal Health Care Program General Enrollment Health Care Provider/Supplier Application	Providers/Suppliers can enroll online using PECOS or the paper enrollment application is located at: https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/enrollment-applications
257	Form CMS-855C - Medicare and Other Federal Health Care Program Change of Information Health Care Provider/Supplier Application	Providers/Suppliers can enroll online using PECOS or the paper enrollment application is located at: https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/enrollment-applications
258	Form CMS-855R - Medicare and Other Federal Health Care Program Individual Reassignment of Benefits Health Care Provider/Supplier Application	Providers/Suppliers can enroll online using PECOS or the paper enrollment application is located at: https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/enrollment-applications
259	Minimum Data Set Automation Contract/Agreement Approval RO Checklist	http://www.cms.gov/manuals/downloads/som107_exhibit_259.pdf
260	MDS Key Field Correction Form	Delete
261	Privacy Act Statement - Health Care Records	http://www.cms.gov/manuals/downloads/som107_exhibit_261.pdf
262	Overview of MDS Version 2.0 Correction Policy for Locked Records	Delete
263	Submission Timeframe for MDS Records	Delete
264	Resident Census and Conditions of Residents - CMS-672	Delete.
265	Roster/Sample Matrix - CMS-802	https://www.cms.gov/medicare/forms-notices/cms-forms-list
266	Roster/Sample Matrix Provider Instructions (Use with Form CMS-802) - CMS-802P	Delete, refer to above Exhibit 265

267	Roster/Sample Matrix Instructions for Surveyors (Use with Form CMS-802) - CMS- 802S	Delete
268	Facility Characteristics	Delete
269	Facility Quality Measure/Indicator Report	Delete
270	Resident Level Quality Measure/Indicator Report: Chronic Care Sample	Delete
271	QM/QI Reports Technical Specifications: Version 1.0	Delete
272	Overview of MDS Submission Record	Delete
273	Correction Policy Summary Matrix	Delete
274	Definition of Important Dates in the RAI Process	Delete
275	Attestation Statement for CMHCs	Delete
277	Fiscal Intermediary (FI) Medicare Provider Billing Number Deactivation Letter Used by FI	Delete
278	Model Denial Letter for CMHC Applicants- State Restrictions on Screening	Delete
279	Model Letter - Notice of Findings for Noncompliance for CMHCs	Delete
280	Model Letter - Notice of Termination of Provider Agreement for CMHCs	Delete

281	Model Letter - CMHC That Has Ceased Operation	Delete
282	Model Letter - Participation in Medicare as a CMHC Providing Partial Hospitalization Services (Including Threshold and Service Requirements)	Delete
283	Model Letter - Notice of Failure to Meet Threshold and Service Requirements, CMHCs	Delete
284	Model Denial Letter - To a Home Health Agency (HHA) That Requested a Branch Office	Delete
285	Worksheet for OBQM & OBQI Reports – Pre- Survey Process and Sample Selection	Delete
286	Hospital/CAH Medicare Database Worksheet	http://www.cms.gov/manuals/downloads/som107_exhibit_286.pdf
287	Authorization by Deemed Provider/Supplier Selected for Validation Survey	http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_287.pdf
288	Surveyor Worksheet For Swing-Beds	http://www.cms.gov/manuals/downloads/som107_exhibit_288.pdf
289	Model Reciprocal Agreement Between States for Survey and Certification of Home Health Agencies and/or Hospices	http://www.cms.gov/manuals/downloads/som107_exhibit_289.pdf
290	Model letter to HHAs Assigning Branch Identification Numbers	Delete

291	Model Notice to Hospital/CAH of Collection of Data by the State Agency	http://www.cms.gov/manuals/downloads/som107_exhibit_290.pdf
292	INSTRUCTIONS FOR COMPLETING THE DATA USE AGREEMENT (DUA) FORM CMS-R-0235	http://www.cms.gov/manuals/downloads/som107_exhibit_292.pdf
293	CMS DUA: ACTS SOR Attachment - P&A	http://www.cms.gov/manuals/downloads/som107_exhibit_293.pdf
294	DUA Multi-Signature Addendum	http://www.cms.gov/manuals/downloads/som107_exhibit_294.pdf
351	Ambulatory Surgical Center Infection Control Surveyor Worksheet	http://www.cms.gov/manuals/downloads/som107_exhibit_351.pdf
352	Notice to a Provider/supplier that Agreement was not Accepted	http://www.cms.gov/manuals/downloads/som107_exhibit_352.pdf
353	Report of a Hospital Death Associated with Restraint or Seclusion (Form CMS-10455)	http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_353.pdf
354	Model Letter To Involved Resident, Resident Representative And/Or State Ombudsman – Opportunity To Provide Written Comment (Independent Informal Dispute Resolution (Idr) Has Been Requested)	http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_354.pdf
355	Probes and Procedures for Appendix J, Part II- Interpretive Guidelines- Responsibilities of Intermediate Care Facilities for Individuals with Intellectual Disabilities	http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_355.pdf

356 Critical Access Hospital (CAH) Recertification Checklist: Rural and Distance or Necessary Provider Verification http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_356.pdf

358 Sample Form for Facility Reported Incidents https://www.cms.gov/files/document/som107exhibit358.pdf

359 Follow-up Investigation Report https://www.cms.gov/files/document/som107exhibit359.pdf