Forms to be Completed by a Medicare Provider Applicant

Along with other application materials that must be submitted to the State Agency, applicants are required to complete and submit the “OCR Information Request Form” and the “HHS Assurance of Compliance Form” in order to obtain civil rights clearance for Medicare certification:

1. Data Request Checklist - Please complete this form and return signed and dated  
2. Assurance of Compliance Form - Please complete this form and return signed and dated  
3. Policies and Procedures - Please submit your civil rights policies and procedures:
   
   • Nondiscrimination Policies and Notices - Learn more about regulatory requirements>>  See sample Nondiscrimination Policy
     
   • Policies and procedures to identify and communicate orally and in writing with persons who have limited proficiency in English (LEP) - Learn more about regulatory requirements>>  See sample LEP Policy
     
   • Policies and procedures to ensure effective communication and auxiliary aids for persons with disabilities - Learn more about regulatory requirements>>  See sample Effective Communication Policy
     
   • A description of your program's accessibility to persons with disabilities - Learn more about regulatory requirements>>    See sample Accessibility Policy
     
   • An explanation for any age restrictions that exist in the medicare provider or applicant's program - Learn more about regulatory requirements>>  
     
   • A Grievance Procedure which incorporates minimum due process standards for patients with a disability - Learn more about regulatory requirements>>    See sample Grievance Procedure