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Cms 1513 (5/86) Form: What You Should Know

E) Are there other directors of the entity owning 50% of its interested in the hospital? Fill Out and Submit Online Form 1515: Confidentiality Agreement — 1515 (8/5) Confidentiality Agreement Confirmation Page 1515 (8/5) — Confidentiality Agreement Submit 1515 online. No need to sign and share. Cm's 1523 — fill Disclosure Of Ownership Form Template, Edit online. Sign and fax or email Confidentiality Agreement. Submit to CMS on or before September 22, 2022 ✓ Confidentiality of Patient Records — 1525 (6/8). Confidentiality of Patient Records. This form protects the confidentiality of all confidential patient information (including any written and personal statements of treatment, and any medical records relating to a patient's illness or treatment) which is maintained, protected, or maintained by any member of the United States Government or any entity participating in the federal programs administered by CMS or the State programs administered by CMS or by other Medicare and Medicaid program administrator. The documents provided here must be returned to the requesting physician by August 15, 2017. Acknowledgements and Disclosures form (Doc 1525 form) must be signed and submitted by the physician by 5:30 p.m. on August 15, 2017. 1525 (6/8). Confidentiality of Patient Records — Confidentiality of Patient Records (Form 1525). This form protects the confidentiality of all confidential patient information (including any written and personal statements of treatment, and any medical records relating to a patient's illness or treatment) which is maintained, protected, or maintained by any member of the United States Government or any entity participating in the federal programs administered by CMS or the State programs administered by CMS or by other Medicare and Medicaid program administrator. The information that is contained within the information submitted along with this form must be returned to the requesting physician by August 15, 2017. Acknowledgements form (Doc 1525 form) must be signed and submitted by the physician by 5:30 p.m. on August 15, 2017. 1526 (5/23). Confidentiality of Patient Records — Confidentiality of Patient Records (Form 1526).

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