Ga. Medicaid Part II Policies & Procedures for Hospital Services § 601

In addition to the completion of a Statement of Participation and a Request for Taxpayer

Identification Number and Certification (IRS Form W-9), a hospital also must submit the following

information:

601.1. A letter from the state licensing unit showing the bed capacity, permit number and effective

date of the permit.

601.2. A document from the state licensing unit showing that the hospital has been recommended for

certification or that it meets the requirements for the Medicare program.

601.3. Written evidence that the hospital is in compliance with Title VI, Civil Rights Act of 1964, as

amended.

601.4. A copy of the written notification to the hospital from the Medicare fiscal intermediary

showing the fiscal year end and Medicare provider number.

601.5. The hospital’s most common semi-private room rate.

601.6. A copy of the hospital’s current Utilization Review Plan.

601.7. Advance Directives Letter of Agreement.

601.8. When the hospital provides mammography services, a copy of the letter of certification that

identifies the mammography certification number.

601.9. A copy of the CMS-1513 form, Disclosure of Ownership and Control Interest statement