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ErtificAtion informAtion in the medicAre progrAm (Please read the following instructions before completing this form) cmS certification number (ccn): Insert the facility s ten-digit CCN. Leave blank on initial requests for certification. 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.

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