CMS-10636 Facility Table

Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)

CY_2018_Facility_HSD_Table_Final - Final for 0938-New - 072417

Three-Year Network Adequacy Review for Medicare Advantage Organizations

OMB: 0938-1346

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1346 can be found here:

2024-06-28 - Revision of a currently approved collection
2023-09-25 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

CY 2018 Facility HSD Table
SSA State/County
Code

Facility or Service
Type

Specialty Code

National Provider
Identifier (NPI) Number

OMB Control Number: 0938-New (Expires: TBD)

# of Staffed, MedicareCertified Beds

Facility Name

Provider Service
Street Address

Provider Service City

Provider Service
State

Provider Service Zip
Code

Uses CMS MA Contract
Amendment (Y or N)

File Type	application/pdf
File Title	HSD Table Templates
Author	CGI Federal
File Modified	2017-07-21
File Created	2016-10-13