U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO 0938-0266 Defendant(s) : ...................................................... AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM (Please see statement on reverse and read the following instructions before completing this form) Submission of this form will initiate the process of obtaining a decision as to participating as a hospital. The number in this block for each related THE completing the whether the Conditions of Coverage are met. Assistance inPEOPLE OF THE STATE OF NEW YORK be the provider number of the highest level of care. provider will form is available from the State agency. NOTE: If an ASC is operated by a hospital, has a Distinct Part SNF, ICF TO Answer all questions as of the currrent date. Return the original and first two and ICF/MR, the related provided number field on the application for each copies to the State agency; retain the last copy for your files. If a return provider (including the hospital) will have the hospital provider number. envelope is not provided, the name and address of the State agency may be State/County and State Region Codes - Leave blank. The Centers for obtained from the nearest Social Security Office. Medicare & Medicaid Services Regional Office will complete. GREETINGS: Detailed instructions are given for questions other than those considered Item III - If a service is provided directly by the facility, place a ‘1’ in the self-explanatory. WE COMMAND YOU, that all business and excusesservicelaid aside, you and each outside attend beforeby appropriate block. If a being is provided through an of you source (i.e., , the supplier number. Court Medicare Supplier Number - Insert the facility’s six-digit Honorable contract orat the referral), place a ‘2’ in the appropriate block. located at County of Leave blank on initial requests for certification. in room , on the day of Item IV - ‘X’ 20 appropriate blocks representing categories at any recessed , the , at o'clock in the noon, and of surgery Related Provider Number - Complete this block when a facility is offered by the ASC. Under “Other,” include only broad categories (i.e., not or adjourned date, to testify and give evidence as a witness in this action on the part of the participating under more than one provider number, such as a facility also subspecialties). Medicare Supplier Number Related Provider Number Name of Facility I IDENTIFYING INFORMATION State Region Code State/County Code AS2 AS1 City, County, and State Fiscal Year Ending Date AS4 AS3 AS5 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Street Address the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Zip Code Telephone No. (Include Area Code) result of your failure to comply. AS6 II III IV TYPE OF CONTROL (x one box) ANCILLARY SERVICES (Place ‘1’ or ‘2’ in blocks) AS8 SURGICAL SPECIALTIES (X appropriate blocks) AS9 V 1. ■ Proprietary AS7 1. ■ Laboratory 1. ■ 2. ■ 3. ■ 4. ■ 5. ■ Cardiovascular Foot General Neurological Obstetrics/Gynecology Witness, Honorable2. ■ Non-Profit Court in County, day of 3. ■ EKG 2. ■ Radiology 6. ■ 7. ■ 8. ■ 9. ■ 10. ■ 4. ■ Pharmacy (Attorney must sign above and type name below) 11. ■ Thoracic 12. ■ Urology 13. ■ Other (Specify) ________________ _____________________________ Attorney(s) for Ophthalmology Oral Orthopedic Otolaryngology Plastic FACILITY 1. Number of Operating Rooms _________________________ CHARACTERISTICS , 20 ,3. ■ of the Justices of the one Government 2. Date Center Began Providing Services _________________________ AS10 AS11 WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATIONAddress STATEMENT, MAY BE Office and P.O. ON THIS PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OR A REQUEST TO PARTICIPATE OR, WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE. Signature of Authorized Official (sign in ink) Form CMS-377 (1-97) Title Telephone No.: Date Facsimile No.: E-Mail Address: Mobile Tel. No.: AS12 American LegalNet, Inc. www.USCourtForms.com