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SSO Request For Carrier Or Intermediary Assistance Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: SSO Request For Carrier Or Intermediary Assistance, CMS-1938, Official Federal Forms Centers For Medicare And Medicaid Services,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Index No.
CENTERS FOR MEDICARE & MEDICAID SERVICES
SSO Request For Carrier or Intermediary Assistance
2. BENEFICIARY NAME
:
1. DATE
2.b. HEALTH :
INSURANCE CLAIM NUMBER
a. SEX
2.c. PHONE
JUDICIAL SUBPOENA NO.
sPlaintiff(s)
M
s F
-against-
CARRIER OR
Calendar No. INTERMEDIARY USE
3. ADDRESS OF BENEFICIARY
:
4. NAME AND ADDRESS OF INQUIRER
IF OTHER THAN BENEFICIARY
4.a. PHONE NO.
:
6. TO (Assisting carrier or . . . . . . . . .
. . . . . . . . . . . . intermediary)
4.b. RELATIONSHIP TO
BENEFICIARY
:
5. NAME OF WE (If different from beneficiary)
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . 7.a.. REQUESTING OFFICE ADDRESS
.. ......
(Send thru parallel SSO unless direct contact permitted)
7.b. PARALLEL OFFICE ADDRESS
THE PEOPLE OF THE STATE OF NEW YORK
TO
PART 1 — SSO REQUEST
8. DESCRIPTION OF SERVICES (Do not complete if EOMB is attached.)
8.a.
PHYSICIAN/SUPPLIER
(Show full
GREETINGS: name and address)
8.b.
DATE(S) OF
SERVICE
8.c.
TYPE/PLACE OF SERVICE
8.d.
AMOUNT
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
9.
s
FURNISH STATUS
OF CLAIM
DATE CLAIM SUBMITTED
10.
s
FOLLOW UP TO ORIGINAL REQUEST
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party s FURNISH THE FOLLOWING INFORMATION (Attach copyfor a maximum penalty of $50 andpertinent.)
on whose behalf this subpoena was issued of EOMB or show intermediary control number if all damages sustained as a
result of your failure to comply.
11. REMARKS OR
Witness, Honorable
Court in
County,
12. PLEASE REPLY TO:
s BENEFICIARY
, one of the Justices of the
day of
s
, 20
INQUIRER
s
REQUESTING OFFICE
s
PARALLEL OFFICE
PART 2 — CARRIER OR INTERMEDIARY REPLY (Return through parallel SSO unless directand type name below)
(Attorney must sign above return is permitted.)
13. REPLY (Continue on reverse side if necessary) OR
s
IS ATTACHED.
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Form CMS-1938 (U2) (1-88)
1 CARRIER OR INTERMEDIARY
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
DEPARTMENT OF HEALTH AND HUMAN SERVICES
:
CENTERS FOR MEDICARE & MEDICAID SERVICES
1. DATE
SSO Request For Carrier or Intermediary Assistance
2. BENEFICIARY NAME
a. SEX
CARRIER OR INTERMEDIARY USE
Calendar No.
2.b. HEALTH INSURANCE CLAIM NUMBER
:
Plaintiff(s)
sM
s F
-against-
3. ADDRESS OF BENEFICIARY
:
Index No.
2.c. PHONE NO.
JUDICIAL SUBPOENA
:
4. NAME AND ADDRESS OF INQUIRER
IF OTHER THAN BENEFICIARY
4.a. PHONE NO.
:
5. NAME OF WE (If different from beneficiary)
4.b. RELATIONSHIP TO
BENEFICIARY
:
Defendant(s) REQUESTING OFFICE ADDRESS
7.a.
:
. .(Send .thru parallel .SSO.unless.direct contact.permitted). . . . . . . . . . . . . . . . . . . . .
... ...... .. ... ....... .....
6. TO (Assisting carrier or intermediary)
7.b. PARALLEL OFFICE ADDRESS
THE PEOPLE OF THE STATE OF NEW YORK
TO
PART 1 — SSO REQUEST
8. DESCRIPTION OF SERVICES (Do not complete if EOMB is attached.)
8.a.
PHYSICIAN/SUPPLIER
8.b.
(Show full
GREETINGS: name and address)
DATE(S) OF
SERVICE
8.c.
TYPE/PLACE OF SERVICE
8.d.
AMOUNT
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
9.
s
FURNISH STATUS
OF CLAIM
DATE CLAIM SUBMITTED
10.
s
FOLLOW UP TO ORIGINAL REQUEST
Your failure toFOLLOWINGwith this subpoena is of EOMB or show intermediary control number if pertinent.) make you liable to
s FURNISH THE comply INFORMATION (Attach copy punishable as a contempt of court and will
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
11. REMARKS OR
Witness, Honorable
Court in
County,
12. PLEASE REPLY TO:
s BENEFICIARY
, one of the Justices of the
day of
s
, 20
INQUIRER
s
REQUESTING OFFICE
s
PARALLEL OFFICE
PART 2 — CARRIER OR INTERMEDIARY REPLY (Return through parallel SSO unless direct return is permitted.)
(Attorney must sign above and type name below)
13. REPLY (Continue on reverse side if necessary) OR
s
IS ATTACHED.
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Form CMS-1938 (U2) (1-88)
2 PARALLEL SSO
American LegalNet, Inc.
www.USCourtForms.com
