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Get cms 1728 form 2013-2024

Ing period being deemed FORM APPROVED as overpayments (42 USC 1395g). OMB NO. 0938-0022 HOME HEALTH AGENCY COST REPORT PROVIDER CCN: CERTIFICATION AND SETTLEMENT SUMMARY PERIOD: From: ___________ _______________ WORKSHEET S To: ___________ Intermediary Use Only: [ ] Audited Date Received ____________ [ ] Initial [ ] Desk Reviewed Contractor No. ____________ [ ] Final [ ] Re-opened PART I - CERTIFICATION Check [ ] Electronically filed cost report Date: ___________ applicab.

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