FI - Physician Acknowledgement Statement for Indian Health Services (Rev. 1040, 09-11-06)

by  Jared Staheli
June 25th, 2015

Section 42 CFR 412.46 requires hospitals to obtain only one signed acknowledgment from physicians who are being granted admitting privileges at a particular IHS provider. The physician must complete the acknowledgment at the time that he/she is granted admitting privileges at the hospital or before, or at the time the physician admits his/her first patient to the hospital. When the hospital submits a claim, it must have on file a signed and dated acknowledgment from the attending physician that the physician has received the notice specified in 42 CFR 412.46(b). Existing acknowledgments signed by physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital.

The IHS providers must meet the conditions specified in 42 CFR 412, Subpart C, to receive payment under IPPS for inpatient hospital services furnished to Medicare beneficiaries.

The IHS providers are monitored to ensure that they are appropriately obtaining the acknowledgment statements from physicians with new admitting privileges as required at 42 CFR 412.46.

For more information on the physician acknowledgement statement see Chapter 4 of Pub. 100-10, Quality Improvement Organization Manual.


FI - Physician Acknowledgement Statement for Indian Health Services (Rev. 1040, 09-11-06). (2015, June 25). Find-A-Code Articles. Retrieved from

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