Form CMS-377 (12/10)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0266
AMBULATORY SURGICAL CENTER REQUEST FOR INITIAL CERTIFICATION
OR UPDATE OF CERTIFICATION INFORMATION IN THE MEDICARE PROGRAM
(Please read the following instructions before completing this form)
Submission of this form will initiate the process of obtaining a decision as to whether
the Conditions for Coverage are met. Assistance in completing the form is available
from the State agency. The ASC completes and signs this form for initial certifications
and upon request of the State agency for the periodic recertification.
Answer all questions as of the current date. Return the original and first two copies
to the State agency; retain the last copy for your files. If a return envelope is not
provided, the name and address of the State agency may be obtained from the
appropriate Regional Office. Please see the following link for additional information:
http://www.cms.gov/RegionalOffices/
Detailed instructions are given for questions other than those considered
self-explanatory.
CMS Certification Number (CCN): Insert the facility’s ten-digit CCN. Leave blank on
initial requests for certification.
State/County and State Region Codes: The ASC leaves this blank.
Item III: If a service is provided directly by the facility, place a ‘1’ in the appropriate
block. If a service is provided under an arrangement with an outside source, place a ‘2’
in the appropriate block. If the service is not provided, leave blank.
Item IV: Place an ‘X’ in the appropriate blocks representing categories of surgery
offered by the ASC. Under “Other,” include only broad categories (i.e., not
subspecialties). More than one block may be checked.
CMS Certification Number
AS1
State/County Code
AS2
State Region Code
AS3
I. IDENTIFYING
INFORMATION
Name of Facility Street Address
City, County, and State Zip Code Telephone No. (Include Area Code)
AS4
II. TYPE OF CONTROL
(Check one box)
AS5
1. Proprietary 2. Non-Profit 3. Government
III. ANCILLARY
SERVICES
(Place ‘1’ or ‘2’ in blocks)
AS6
1. Laboratory 2. Radiology 3. Pharmaceutical Services
IV. SURGICAL
SPECIALTIES
(X appropriate blocks)
AS7
1. Dental
2. Endoscopy
3. Ear/Nose/Throat
4. Ob/Gyn
5. Ophthalmologic
6. Orthopedic
7. Pain
8. Plastic/reconstructive
9. Podiatry
10. Other(Specify)
V. FACILITY
CHARACTERISTICS
1. Number of Operating Rooms/Procedure Rooms _______________
AS8
2. Date Center Began Providing Services _______________
AS9
WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT, MAY BE PROSECUTED UNDER
APPLICABLE FEDERAL AND STATE LAWS.
Signature of Authorized Official (sign in ink) (required only for initial certification)
Title Date
AS10
According to the Paperwork Reduction of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0266. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, searching
existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimates(s) or suggestions for
improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
