Form CMS-724 Medicare/Medicaid Psychiatric Hospital Survey Data

FORM APPROVED
OMB NO. 0938-0378

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE/MEDICAID PSYCHIATRIC HOSPITAL SURVEY DATA

SECTION I: to be completed by hospital
Name of Hospital

Street Address

State

B2

B1

Hospital Provider Number

City or County

Total Number of Beds

B4

B3

Total Number of Certified Beds

ZIP Code

B5

Other Data — Does the hospital operate a forensic unit?

■ Yes
B7

B6

■ No
B9

B8

For the past year: A. Total number of admissions to certified areas

B. Age Range of Patients

from (month)__________ (year)___________

B10

C. Medicare/Medicaid Billings

B11

D. Other Data — Does the hospital operate a separate MEDICAID ONLY-Residential
Treatment Program for Psychiatric patients under the age of 22?

Billed

Collected

■ Yes

MEDICARE/Part A

■ No

MEDICARE/Part B
MEDICAID

B12

13. Current Hospital Statistics (on days of survey) [certified beds only]

Name of Ward

Bed Capacity

Patient Census

Total Patient Census
Form CMS-724 (0378)

B13

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FORM APPROVED
OMB NO. 0938-0378

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE/MEDICAID PSYCHIATRIC HOSPITAL SURVEY DATA (contd)
SECTION II: to be completed by the survey team
Dates of Survey (beginning)

Dates of Survey (ending date)

___ ___/ ___ ___/ ___ ___
(mm)

(day)

___ ___/ ___ ___/ ___ ___
(mm)

(year)
B14

Administrator
Nurse
Dietician
Pharmacist
Social Worker
LSC Specialist
Sanitarian
Physician
Psychologist
Other ___________

(day)

(year)

■ Initial (B16)

■ Recertification (B17)

■ Follow-up (B18)

■ Complaint (B19)

■ Second Follow-up (B20)

■ Concurrent with
General Hospital (B21)

B15

Survey Team Composition

■
■
■
■
■
■
■
■
■
■

Type of Survey:

Total Number of Surveyors on Site

(B22)
(B23)
(B24)
(B25)

■
■
■
■

SA
RO
Consultant
CO

(B32)
(B33)
(B34)
(B35)

(B26)
(B27)
(B28)
(B29)
(B30)

Total Number of Surveyors on Site ________

(B36)

(B31)

19. Certification of Findings

I certify that I have reviewed each Condition of Participation and Related Standards for Psychiatric Hospitals, and unless indicated on the CMS-2567,
the Facility was found to be in compliance with the Conditions and/or Standards.
Signature

Title

Date

Signature

Title

Date

Signature

Title

Date

Signature

Title

Date

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 collectio
n is 0938-0378 Expiration Date: XX/XX/XXXX. The time required to complete this information collection is estimated to average 15 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 any 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, C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****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 HospitalSCG@cms.hhs.gov.
Form CMS-724 (0378)

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