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DEPDEPARARTMENTTMENT OF HEALOF HEALTHTH AND HUMAN SERAND HUMAN SERVICESVICES Form ApprovedForm Approved
CENTERS FOR MEDICARE & MEDICAID SERCENTERS FOR MEDICARE & MEDICAID SERVICESVICES OMB No. 0938-0600OMB No. 0938-0600
MEDICARE CREDIT BALANCE REPORT
CERTIFICATION PAGE
The Medicare Credit Balance Report is required under the authority of sections 1815(a), 1833(e),
1886(a)(1)(C) and related provisions of the Social Security Act. Failure to submit this report may result in a
suspension of payments under the Medicare program and may affect your eligibility to participate in the
Medicare program.
ANYONE WHO MISREPRESENTS, FALSIFIES, CONCEALS OR OMITS ANY ESSENTIAL
INFORMATION MAY BE SUBJECT TO FINE, IMPRISONMENT OR CIVIL MONEY PENALTIES
UNDER APPLICABLE FEDERAL LAWS.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER
I HEREBY CERTIFY that I have read the above statements and that I have examined the accompanying credit
balance report prepared by
for the calendar quarter ended_____________________and that it is a true, correct, and complete statement
prepared from the books and records of the provider in accordance with applicable Federal laws, regulations
and instructions.
Provider Name Provider 6-Digit Number
(Sign) ____________________________________________
Officer or Administrator of Provider
(Print) ____________________________________________
(Print) ____________________________________________
Name and Title
Date
CHECK ONE:
❑ Qualify as a Low Utilization Provider.
❑ The Credit Balance Report Detail Page(s) is attached.
❑ There are no Medicare credit balances to report for this quarter. (No Detail Page(s) attached.)
Contact Person Telephone Number
Form CMS-838 (10/03)Form CMS-838 (10/03)
INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT -
PROVIDER INSTRUCTIONS, FORM CMS-838