Physician Acknowledgement

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The law requires hospitals that are paid under the prospective payment system (PPS) to obtain a signed acknowledgement from physicians who have admitting privileges at a particular hospital. The physician must complete the acknowledgement when he or she receives admitting privileges or before or at the time the doctor admits his or her first patient to the hospital.

When the hospital submits a claim, it must have on file a signed and dated acknowledgement from the attending physician that the physician received the notice. Existing acknowledgements from physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital. Your state’s Beneficiary and Family Centered Care-QIO (BFCC-QIO) monitors this process annually.

You can identify your state’s BFCC-QIO using our interactive map or by referencing the BFCC-QIO listing below. 

BFCC-QIO Contact Information by Region or State

Northeast and Caribbean:  Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Virgin Islands, Vermont

Download Livanta’s Physician Acknowledgement Form

Mid-Atlantic and Southeast:  Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia

Download KEPRO’s Physician Acknowledgement Form

Mountain, North Central and South:  Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah, Wyoming

Download KEPRO’s Physician Acknowledgement Form

Midwest:  Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, Wisconsin

Download KEPRO’s Physician Acknowledgement Form

West:  Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon, Washington

Download Livanta’s Physician Acknowledgement Form