Credit Balance Report

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(No Detail Page(s) attached.) Contact Person Telephone Number Form CMS-838 (10/03) INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT PROVIDER INSTRUCTIONS, FORM CMS-838 HIC Number Beneficiary Name Form CMS-838 (10/03) (2) (1) Type of Bill (6) Admission Discharge Date Date (MM/DD/YY) (MM/DD/YY) (8) Paid Date Cost Report (MM/DD/YY) (Open/Closed) (7) (9) Amount of Medicare Credit Balance (10) Amount of Medicare Credit Balance Repaid (11) Method of Payment (12) Amount of Medicare Credit Balance Outstanding (13) (14) Reason for Medicare Value Credit Balance Code INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT - PROVIDER INSTRUCTIONS, FORM CMS-838 ICN Number (3) (5) Primary Payer (Name Billing Address) (15) Phone Number ()- Quarter Ending: (4) Contact Person: Provider Number: Medicare Part: (Indicate “A” or “B”) Pageof Detail Page Medicare Credit Balance Report 2 Form Approved OMB No.. If there are multiple provider numbers for dedicated units within the facility (e.g., psychiatric, physical medicine and rehabilitation), complete a separate Medicare Credit Balance Report for each provider number • The month, day and year of the reporting quarter e.g., 12/31/02 • An “A” if the report page(s) reflects Medicare Part A credit balances, or a “B” if it reflects Part B credit balances • The number of the current detail page and the total number of pages forwarded, excluding the certification page (e.g., Page 1 of 3) and • The name and telephone number of the individual who may be contacted regarding any questions that may arise with respect to the credit balance data.. For code description, see each provider manual has the appropriate cite for that manual .) 12 – Working Aged 13 – End Stage Rena

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