Forms to be Completed by a Medicare Provider ApplicantAlong 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: - Data Request Checklist - Please complete this form and return signed and dated
- Assurance of Compliance Form - Please complete this form and return signed and dated
- Policies and Procedures - Please submit your civil rights policies and procedures:
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