US · guidance
CMS Pub. 100-06, ch. 6, § 80.4
Form Heading
A3-3899.4
The intermediary enters its name, assigned number and the State in which the provider is located.
In the space labeled "Reporting Period", it enters the numeric designation for month and year for
which the report is being prepared, e.g., it shows 01/02 for January 2002.
History
(Rev. 6, 08-30-02)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
da93755e53503a9f2602cded8d16d09293556592f4cf56512328838942b2590a
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