This form contains 26 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Authorization
Signature of Representative for Facility Surveyed	Signature	Provide the signature of the representative for the facility surveyed.
Title of Person Signing Form	Text	Enter the title of the person signing the form.
Corrective Actions
Plan of Correction	Text	Outline the plan of correction for the deficiencies found.
Completion Date	Text	Enter the date by which the corrective actions will be completed.
Plan of Correction (continued)	Text	Outline the plan of correction for the deficiencies found (continued).
Completion Date (X5) continued	Text	Enter the date by which the corrective actions will be completed (continued).
Deficiency Details
ID Prefix Tag	Text	Enter the ID Prefix Tag associated with the deficiency.
Summary Statement of Deficiencies	Text	Provide a summary statement of the deficiencies found during the survey.
ID Prefix Tag	Text	Enter the ID Prefix Tag associated with the deficiency.
ID Prefix Tag (X4) continued	Text	Enter the ID Prefix Tag associated with the deficiency (continued).
Summary Statement of Deficiencies (continued)	Text	Provide a summary statement of the deficiencies found during the survey (continued).
ID Prefix Tag (continued)	Text	Enter the ID Prefix Tag associated with the deficiency (continued).
Document Information
Page Number	Text	Enter the current page number of this form. This helps in organizing multi-page documents.
Total Number of Pages	Text	Enter the total number of pages in this form. This ensures that all pages are accounted for.
Facility Identification
Provider/Supplier/CLIA ID Number	Text	Enter the unique Provider/Supplier/CLIA ID Number assigned to the facility.
Multiple Construction - Building	Text	Specify the building if the facility has multiple constructions.
Multiple Construction - Wing	Text	Specify the wing if the facility has multiple constructions.
Name of Facility Surveyed	Text	Enter the name of the facility that was surveyed.
Facility Address	Text	Enter the full address of the facility that was surveyed.
Name of Facility Surveyed	Text	Enter the name of the facility that was surveyed.
Form Navigation
Page Number	Text	Enter the current page number of the form.
Total Number of Pages	Text	Enter the total number of pages in the form.
Signature Information
Date Signed	Text	Enter the date when the form was signed by the facility's representative. Use the format MM/DD/YYYY.
Survey Details
Date Survey Completed	Text	Enter the date when the survey was completed.
Name of AO Performing Survey (if applicable)	Text	Enter the name of the Accrediting Organization (AO) that performed the survey, if applicable.
Date Survey Completed	Text	Enter the date when the survey was completed.

Form CMS-2567, Statement of Deficiencies Instructions