Free 51865.pdf - Indiana

HOSPITAL / CAH MEDICARE DATABASE WORKSHEET
State Form 51865 (R3 / 5-09)

Indiana State Department of Health-Division of Acute Care

CMS Certification Number (CCN): ___________________ Date of Worksheet Update: ______________ Medicaid Provider Number: ___________________ (MMDDYY) ____________ (M1)

National Provider Identification Number(s) (NPI): ___________________________________ Fiscal Year Ending Date (MMDD): _____________ Name and Address of Facility (Include City, State): __________________________________________________________________________ __________________________________________________________________________ _________________________________________________ZIP Code: ________________ Telephone Number (M2):_______________________ CEO Telephone Number: ___________________ Email Address: ________________________ Website Address: ______________________ Fax Number (M3): _____________________

Accreditation Status: _____ Effective Date of Accreditation: _____________________ 0 Not Accredited 1 JC Accredited 2 AOA Accredited 3 DNV (MMDDYY) (M4) Renewal Date of Accreditation:_____________________ (MMDDYY) (M5)

Multiple Accreditation Status:

Yes

No

(Select all others that apply; do not include the primary accreditation organization): JC AOA DNV

State/County Code (M6):__________

State Region Code (M7):__________

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Type of Program Participation (M8):_____

CLIA ID Numbers (M9):

Select One 1 Medicare 2 Medicaid 3 Medicare & Medicaid

________________________________ ________________________________ ________________________________ ________________________________ ________________________________

Medicare CAH Status or Type of Medicare Hospital (select one) (M10):_____ 01 Short-term 02 Long-term 06 Childrens 07 Distinct Part Psychiatric Hospital 08 Cancer Hospital 11 Critical Access Hospital (CAH)

03 Religious Nonmedical Health Care Institution 04 Psychiatric 05 Rehabilitation

Affiliation with a Medical School (M11):_____ 01 Major 02 Limited 03 Graduate School

04 No Affiliation

Resident Programs (M12) (select all that apply):____________________________ 01 Allopathic 02 Dental 03 Osteopathic 04 Other 06 Podiatric

Ownership Type (select one) (M13):______ 01 02 03 04 05 Church Private (Not for Profit) Other (specify):________________ Private (For Profit) Federal 06 State 07 Local 08 Hospital District or Authority 09 Physician Ownership 10 Tribal Number of Staffed Beds (M15):_______ 2

Average Daily Census (M14):______

Type of Chain/Health System Involvement (M16):______ 01 None 02 System Ownership 03 System Management Name of System (M17):______________________________________________________________ Corporate Headquarters City (M18):_________________________________ State (M19):______

Number of Employees Salaried by Hospital/CAH (Use Full Time Equivalents FTE) M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 Physicians (Salaried only) Physicians - Residents Physician Assistants (PA) Nurses - CRNA Nurses - Practitioners Nurses - Registered Nurses ­ LPN Dieticians Medical Social Workers Medical Laboratory Technicians M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 Medical Technologists (Lab) Nuclear Medicine Technicians Occupational Therapists Pharmacists (Registered) Physical Therapists Psychologists Radiology Technicians (Diagnostic) Respiratory Therapists Speech Therapists All Others

Medicare Payment-Related Categories for a Hospital or a CAH (select all that apply) (M40):_______ CAH Categories 01 CAH Psychiatric DPU 02 CAH Rehabilitation DPU 03 CAH Swing Beds Hospital Categories 07 Hospital PPS Excluded Psych Unit 08 Hospital PPS Excluded Rehab Unit 09 Hospital Swing Beds 10 Medicare Dependent Hospital 11 Regional Referral Center 12 Sole Community Hospital

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Services Provided by the Facility (M41):______
0 1 2 3 Service not provided Services provided by facility staff only Services provided by arrangement or agreement Services provided through a combination of facility staff and through agreement 34 02 03 04 Alcohol and/or Drug Services Anesthesia Service Audiology 38 06 07 08 09 10 11 12 13 14 16 17 Burn Care Unit Cardiac Catheterization Laboratory Cardiac-Thoracic Surgery Chemotherapy Service Chiropractice Service CT Scanner Dental Service Dietetic Service Emergency Department (Dedicated) Extracorporeal Shock Wave Lithotripter Gerontological Specialty Services 39 40 41 42 43 44 45 46 47 48 49 50 51 52 20 21 22 23 24 26 28 29 30 31 32 33 ICU - Cardiac (non-surgical) ICU - Medical/Surgical ICU - Neonatal ICU - Pediatric ICU - Surgical 58 Laboratory - Clinical Magnetic Resonance Imagining (MRI) Neonatal Nursery Neurosurgical Services Nuclear Medicine Services Obstetric Service Occupational Therapy Services 59 60 61 62 63 64 65 66 Rehab - Outpatient Renal Dialysis (Acute Inpatient) Social Services Speech Pathology Services Surgical Services - Inpatient Surgical Services - Outpatient Trauma Center (Designated) Transplant Center (Medicare Certified) Urgent Care Center Services 53 54 55 56 Organ Transplant Services (Not Medicare-certified) Orthopedic Surgery Outpatient Services Pediatric Services Pharmacy Physical Therapy Services Positron Emission Tomography Scan Post-Operative Recovery Rooms Psychiatric Services - Emergency Psychiatric - Child/Adolescent Psychiatric - Forensic Psychiatric - Geriatric Psychiatric - Adult Inpatient Psychiatric - Outpatient Radiology Services - Diagnostic Radiology Services - Therapeutic Reconstructive Surgery Respiratory Care Services Rehab Services - Inpatient 35 36 Operating Rooms Opthalmic Surgery Optometric Services

Sprinkler Status, Main Campus (select one) (M42): ________ 01 Totally sprinklered: All required areas are sprinklered 02 03 Partially sprinklered: Some but not all required areas are sprinklered Sprinklers: No required areas are sprinklered 4

Total number of provider-based off-site locations under the same CCN (M43):_______

TYPES OF OFF-SITE LOCATIONS 01 Inpatient Remote Location 02 Offsite Outpatient Surgery 03 Offsite Urgent Care Center 04 Satellite of a Rehabilitation Hospital 05 Satellite of a Psychiatric Hospital 06 Satellite of an IPPS-Excluded Rehab Unit 07 Satellite of an IPPS-Excluded Psych Unit 08 Satellite of a Long Term Care Hospital 09 Satellite of a Cancer Hospital 10 Satellite of a Childrens' Hospital 11 Offsite Emergency Department 12 Other Provider-Based Offsite Facility/Department

For each off-site location, complete and attach the Provider-Based Off-Site Locations Continuation Worksheet.

Number of related or affiliated providers or suppliers (M44):_______

TYPES OF AFFILIATED PROVIDERS/SUPPLIERS 01 Ambulance Service 02 Ambulatory Surgery Center 03 End Stage Renal Disease 04 Federally Qualified Health Center 05 Home Health Agency 06 Hospice 07 Organ Procurement Organization 08 Psychiatric Residential Treatment Facility 09 Rural Health Clinic 10 Skilled Nursing Facility (SNF)

For each affiliated provider/supplier, complete and attach the Affiliated Provider/Supplier Continuation Worksheet, indicating the provider/supplier name, CCN, and type. (M45) Co-location Status: Is there another hospital, or a satellite location of another hospital, that occupies space in a building used by the hospital described in this worksheet? 01 02 Yes No

If yes, provide the name and CCN number of the co-located hospital:

Name________________________________________________ CCN_____________________ 5

PROVIDER-BASED OFF-SITE LOCATION CONTINUATION WORKSHEET PAGE 1 OF _______ ENTRY NUMBER _____ Type of Off-site Location (from table M43): _______ Name of Off-Site Location: __________________________________________________________ Off-Site Street Address: _____________________________________________________________ County: __________________________________________________________________________ City: _______________________________ State:__________________ ZIP Code:______________ Sprinklered Status of Off-site Location (select one): _______________ 01 Totally sprinklered: All required areas are sprinklered; 02 Partially sprinklered: Some but not all required areas sprinklered; Sprinklers: No required areas are sprinklered 03 04 Sprinklers are not required

ENTRY NUMBER _____ Type of Off-site Location (from table M43): _______ Name of Off-Site Location:___________________________________________________________ Off-Site Street Address: _____________________________________________________________ County: ___________________________________________________________________________ City: _______________________________ State:__________________ ZIP Code:_______________ Sprinklered Status of Off-site Location (select one): _______________ Totally sprinklered: All required areas are sprinklered; 01 02 Partially sprinklered: Some but not all required areas sprinklered; Sprinklers: No required areas are sprinklered 03 04 Sprinklers are not required ENTRY NUMBER _____ Type of Off-site Location (from table M43): _______ Name of Off-Site Location:_____________________________________________________________ Off-Site Street Address: _______________________________________________________________ County: ____________________________________________________________________________ City: _______________________________ State:__________________ ZIP Code:________________ Sprinklered Status of Off-site Location (select one): _______________ 01 Totally sprinklered: All required areas are sprinklered; 02 Partially sprinklered: Some but not all required areas sprinklered; 03 Sprinklers: No required areas are sprinklered Sprinklers are not required 04 Make additional copies as needed for additional off-site locations.

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AFFILIATED PROVIDER/SUPPLIER CONTINUATION WORKSHEET PAGE 1 OF_____ Identify all affiliated Medicare-certified providers/suppliers, indicating for each the name, CCN, and type of provider/supplier, using the codes from M44.

Entry Number _____ Name________________________________________________ CCN_______________________ Type of Provider/Supplier _________

Entry Number _____ Name________________________________________________ CCN_______________________ Type of Provider/Supplier _________

Entry Number _____ Name________________________________________________ CCN_______________________ Type of Provider/Supplier _________

Entry Number _____ Name________________________________________________ CCN_______________________ Type of Provider/Supplier _________

Entry Number _____ Name________________________________________________ CCN_______________________ Type of Provider/Supplier _________

Make additional copies as needed for additional affiliated providers/suppliers.

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