DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCOURT COUNTY OFCENTERS FOR MEDICARE & MEDICAID SERVICESOMB No. 0938-0655. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CLIA ADVERSE ACTION:::::::Index No.CMS FORM 462A: HARD COPY TO BE COMPLETED BY THE STATE OR RO:Calendar No.2. LABORATORY NAME AND ADDRESS:1. PROVIDER NUMBER (CLIA ID number):3. FORM ORIGINATION DATE:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)M MYY DD5. OPERATOR(S) (First Name, Last Name, Middle Initial): *4. OWNER(S) (First Name, Last Name, Middle Initial):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ORIGIN OF ENFORCEMENT ACTIONTHE PEOPLE OF THE STATE OF NEW YORK TO6. TYPE OF EVENT:SURVEY DATE: INITIAL SURVEYM M D D Y Y RECERTIFICATION SURVEY RANDOM SAMPLE VALIDATION SURVEY (For accredited, CLIA exempt, waived laboratories or laboratories holding certificates forGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorablephysician-performed microscopy procedures) COMPLAINT SURVEY REVISIT UNSUCCESSFUL PARTICIPATION IN PT............................................................ (DATE REPORTED),located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomM M D D Y Y NON-PAYMENT OF FEE ....................................................................................... (DATE DUE) ACTION BY THE INSPECTOR GENERALYour 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 $50 and all damages sustained as a result of your failure to comply.M M D D Y Y7. SURVEY RELATED BASIS OR BASES FOR ADVERSE ACTION (Specify all that apply):, one of the Justices of theCourt in Witness, Honorableday of, 20 County, CONDITION LEVEL NONCOMPLIANCE WHICH DOES NOT POSE IMMEDIATE JEOPARDY IMMEDIATE JEOPARDY (DATE JEOPARDY REMOVED, IF APPLICABLE)M M D D Y Y TESTING WITHOUT THE APPROPRIATE CLIA CERTIFICATE(Attorney must sign above and type name below) REFUSAL TO COOPERATE WITH SURVEY TEAM'S REQUESTS REFUSAL TO PROVIDE INFORMATION REQUESTED BY CMS OR ITS AGENT LABORATORY OWNER, OPERATOR, OR EMPLOYEE MEETS THE CRITERIA SET FORTH AT §493.1840 STANDARD LEVEL NONCOMPLIANCE NOT CORRECTED WITHIN 12 MONTHS OR BY DATE SPECIFIED ONAttorney(s) forOffice and P.O. AddressTHE PLAN OF CORRECTION8. DATE(S) OF REVISIT(S):Telephone No.: Facsimile No.: E-Mail Address:M M D D Y YM M D D Y YM M D D Y Y* Note: Operators include the Responsible Laboratory Directors.Mobile Tel. No.:Form CMS-462A/B (05/97)Page 1American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OFDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CLIA ADVERSE ACTION:::::::Index No.CMS FORM 462B (ON ODIE ONLY):Calendar No.9. DATE FINAL NOTICE OF SANCTION SENT TO THE10. DATE FIRST ADVERSE ACTION IMPOSED:LABORATORY:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)M MYYM MYY (5 days prior to the imposition of the sanction for an immediate jeopardy situation, 15 days prior to the imposition of the sanction for a non-immediate jeopardy situation.)DDDDINDICATE SANCTIONS IMPOSED:11. INTERMEDIATE SANCTION:EFFECTIVE DATEDATE RESCINDED1. CIVIL MONEY PENALTY($.)M M D D Y YM M D D Y YSpecify: per day$.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .per violation$.2. STATE ONSITE MONITORINGTHE PEOPLE OF THE STATE OF NEW YORK TOM M D D Y YM M D D Y Y3. DIRECTED PLAN OF CORRECTIONM M D D Y YM M D D Y Y4. SUSPENSION OF PART OF MEDICARE/MEDICAID PAYMENTSGREETINGS:M M D D Y YM M D D Y Y5. SUSPENSION OF ALL MEDICARE/MEDICAID PAYMENTWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,M M D D Y YM M D D Y Ylocated at County of12. PRINCIPAL SANCTION:o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room1. CANCELLATION OF MEDICARE/MEDICAID APPROVAL (Check box 'D' if action is due to denial of application for aM M D D Y YDM M D D Y YYour 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.CLIA certificate) 2. REVOCATION OF CLIA CERTIFICATE (Check box 'D' if action is due to denial of application for aM M D D Y YDM M D D Y YCLIA certificate) 3. SUSPENSION OF CLIA CERTIFICATE, one of the Justices of theM M D D Y YM M D D Y YCourt in Witness, Honorableday of, 20 County,4. LIMITATION OF CLIA CERTIFICATE (Complete ITEM below)M M D D Y YM M D D Y Y(Attorney must sign above and type name below)SPECIALTIES/SUBSPECIALTIES/ANALYTES WHICH THE LABORATORY IS NOT AUTHORIZED TO TEST, BASED ON THE LIMITATION OF ITS CLIA CERTIFICATE:Attorney(s) forSPEC / SUBS / ANALYTESPEC / SUBS / ANALYTESPEC / SUBS / ANALYTESPEC / SUBS / ANALYTESPEC / SUBS / ANALYTESPEC / SUBS / ANALYTEOffice and P.O. AddressSPEC / SUBS / ANALYTESPEC / SUBS / ANALYTESPEC / SUBS / ANALYTE13. ADDITIONAL ENFORCEMENT ACTION: TRAINING AND TECHNICAL ASSISTANCE FOR UNSUCCESSFUL PARTICIPATION IN PT:Telephone No.: Facsimile No.: E-Mail Address:DATE ENDEDDATE BEGUNM M D D Y YM M D D Y YMobile Tel. No.:Form CMS-462A/B (05/97)Page 2American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF14. DENIAL OF CLIA CERTIFICATION:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .M M D D Y Y:::::::Index No.15. VOLUNTARY WITHDRAWAL OF TESTING (SPECIFY SPECIALTIES/SUBSPECIALTIES/ANALYTES, AND DATES THAT CMS WAS NOTIFIED OF THECalendar No.WITHDRAWAL):JUDICIAL SUBPOENAPlaintiff(s)SPEC / SUBS / ANALYTESPEC / SUBS / ANALYTESPEC / SUBS / ANALYTE-against-M M D D Y YM M D D Y YM M D D Y YSPEC / SUBS / ANALYTESPEC / SUBS / ANALYTESPEC / SUBS / ANALYTEDefendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .M M D D Y YM M D D Y YM M D D Y Y16