DEPARTMENT OF HEALTH & HUMAN SERVICES PROVIDER REIMBURSEMENT REVIEW BOARD 2520 Lord Baltimore Drive, Suite L Baltimore, MD 21244-2670 Phone: 410-786-2671 MODEL FORM A – INDIVIDUAL APPEAL REQUEST Date of Request: ____________________________________ Provider Name: _____________________________________ Provider Number: ___________________________________ Fiscal Year Ended: __________________________________ Intermediary/MAC: _________________________________ Notice of Final Determination Dated: ____________________________ YOU MUST ATTACH THE FINAL DETERMINATION UNDER A TAB LABELED 1. *If claiming intermediary/MAC failed to issue a timely Final Determination, state date cost report was sent to intermediary: ____________________________ (Include copy of the cost report certification page and any other evidence to support the date the cost report was filed.) Does this Request for Hearing include a request for Expedited Judicial Review? _____ YES _____ NO (Note: A request for EJR must be submitted in a separate document and “EJR Request” must be marked on the outside of the envelope.) Is the Provider requesting Mediation? (If yes, a request must be submitted in a separate document.) _____ YES _____ NO Provider Information: Provider Name: _______________________________________________ Provider Contact/Title: _________________________________________ Provider Address: __________________________________________ __________________________________________ __________________________________________ Provider Telephone Number: ________________________ Provider FAX Number: ____________________________ E-mail address: ______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Is this Provider commonly owned or controlled? _____ YES _____ NO If YES, identify the name of the corporation, name of the contact person at the corporation, the address and telephone number: ______________________________________________ ______________________________________________ ______________________________________________ Intermediary/MAC Information: Intermediary/MAC Name: ________________________________________ Address: ________________________________________ ________________________________________ ________________________________________ Intermediary/MAC Code: ________________________________________ (From NPR, if known) Representative Information (if applicable): Representative’s Name: ____________________________________________ Company Name and Address: _______________________________________ _______________________________________ _______________________________________ Phone Number: ___________________________ Fax Number: _____________________________ E-mail Address: _______________________________ If you are filing as a representative, UNDER A TAB LABELED 2 YOU MUST ATTACH A LETTER SIGNED BY THE PROVIDER AUTHORIZING REPRESENTATION Issue(s) Appealed: UNDER A TAB LABELED 3 YOU MUST SUBMIT A STATEMENT OF THE ISSUE. The statement of the issue must conform to the requirements of the regulations found at 42 C.F.R. § 405.1835 et seq. and the Board’s Rules and include: (1.) Description of the issue; (2.) The audit adjustment number(s); if applicable or other evidence required by 42 C.F.R. § 405.1835 (a)(1)(ii); (3.) The amount in controversy; and (4.) A statement identifying the legal basis for the appeal (Cite statutes, regulations and/or manual provisions.). Total Amount in Controversy for all issues: ______________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATIONS A. I certify that none of the issues filed in this appeal are pending in any other appeal for the same period and provider, nor have they been adjudicated, withdrawn, or dismissed from any other PRRB appeal. Printed Name: ______________________________________ Title: __________________________________ Signature: __________________________________________ (Provider Owner/Officer/Director or Representative) Date: _______________________ B. I certify to the best of my knowledge that there are no other providers to which this provider is related by common ownership or control that have a pending request for a Board hearing on any of the same issues for a cost reporting period that ends in the same calendar year covered in this request. See 42 C.F.R. § 405.1835 (b)(4)(i). Signature: __________________________________________ (Provider Owner/Officer/Director or Representative) Date: _______________________ C. I certify that a copy of this Request (and any supporting documentation) was sent by (Check one) _____ United States Postal Service _____ Nationally recognized courier. Specify name: ________________________________ to the intermediary/MAC on this __________day of ______________, 2 _____. Certified Mail or Tracking Number: __________________________________ Signature: __________________________________________ (Provider Owner/Officer/Director or Representative) Date: _________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com