DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 20017 ADVISORY PANEL ON hOSPItAL OutPAtIENt PAYmENt Presenter/Presentation Information Checklist Instructions: Send this hardcopy checklist (Parts I and II) with your presentation to the following address by 5 p.m. on the date specified in the Federal Register notice: Raymond Bulls Designated Federal Official, HOP Panel CMS/CMM/HAPG/DOC 7500 Security Blvd., C4-05-17 Baltimore, MD 21244-1850 E-mail address: Raymond.Bulls@cms.hhs.gov Part I: Personal Information for Presenter(s) (If you have more than three presenters, photocopy the form, or go to http://www.cms.hhs.gov/cmsforms/downloads/cms20017.pdf to print another copy.) Presenter's Name Title Organizational Affiliation, Name, Address, City, and State Subject of Presentation E-mail Address Telephone Number Clearly describe the action(s) that you are requesting CMS to take. Presenter's Name Title Organizational Affiliation, Name, Address, City, and State Subject of Presentation E-mail Address Telephone Number Clearly describe the action(s) that you are requesting CMS to take. Form CMS-20017 (07/12) American LegalNet, Inc. www.FormsWorkFlow.com 1 Part II � Presentation Required Checklist In order to meet the presentation requirements, all information stated below must be on page 1 of your presentation in a clear, logical format. To ensure that all information has been supplied--which is required for each presentation at the APC Panel meeting--please provide the following: 1. List the financial relationship of presenter(s), if any, with any company whose product, services, or procedures are under consideration 2. Physicians' Current Procedural Terminology (CPT) code(s) and Health Care Common Procedures Codes (HCPS) involved 3. APC(s) affected 4. Description of the issue(s) 5. Clinical description of the service under discussion (with comparison to other services within the APC) 6. Recommendations and rationale for change 7. Recommendations and rationale for change 8. Potential consequences of not making the change Form CMS-20017 (07/12) American LegalNet, Inc. www.FormsWorkFlow.com 2