CMS Pub. 100-04, ch. 32, § 360.3.1

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

REFER TO:

Identification Number:___________________

Dear _________________:

Your election to bill the Medicare program for emergency services furnished to Medicare beneficiaries will expire on

December 31. Payment for emergency services can be made to a nonparticipating hospital only if the hospital elects to

receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year.

If you elect to bill the program, please return to us in the enclosed self-addressed envelope a statement signed by an

authorized official of your hospital stating that you elect to claim payment under the Medicare program. An election to

bill cannot be withdrawn during the year. If a statement is not received by December 31, we will assume that you do not

wish to continue to bill the program at this time. However, you still retain the right to elect to bill the program at any

time during the coming year if, when you make your election, you have not yet charged any Medicare beneficiary in that

year for emergency hospital services rendered to him.

Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting

the MAC serving nonparticipating hospitals in your State. If you do not elect to bill, the beneficiary may apply for

reimbursement by submitting an itemized bill.

Please contact us if you need any further information. In addition, if at any time you decide to request full participation

as a provider of hospital services under the Medicare program, please contact your Medicare MAC for complete

particulars.

Sincerely,