Calendar Worksheet-Prescribed Visits
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Calendar Worksheet-Prescribed Visits Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Calendar Worksheet-Prescribed Visits, CMS-1515F, Official Federal Forms Centers For Medicare And Medicaid Services,
:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Plaintiff(s)
CALENDAR WORKSHEET Freq/wks
Freq/wks
Freq/wks
-againstPRESCRIBED
VISITS
Calendar No.
:
JUDICIAL SUBPOENA
FORM APPROVED
OMB NO. 0938-0355
:
:
Freq/wks
:
SN
Defendant(s)
:
......................................................
HHA
PT
OT
ST
MSW
SOC DATE:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-0355. The OF required to complete this information collection is estimated to average 1 hour 10 minutes per
THE PEOPLE OF THE STATEtime NEW YORK
response, including the time to review instructions, searching existing data resources, gather the data needed, and
complete and review the information collection. If you have any comments concerning the accuracy of the time
TO
estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer,
7500 Security Boulevard, Baltimore, Maryland 21244-1850.
GREETINGS:
Fill in days of week; begin with SOCbusiness and excuses being laid aside, you and each of you attend before
WE COMMAND YOU, that all date/day
,
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
WEEK 1
WEEK 2
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
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.
WEEK 3
Court in
Witness, Honorable
County,
, one of the Justices of the
day of
, 20
WEEK 4
WEEK 5
WEEK 6
WEEK 7
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
WEEK 8
WEEK 9
FORM CMS-1515F (06/90)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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