. OF . . . . . . . . HUMAN . . . . . . . DEPARTMENT . . . HEALTH. AND . . . . . . SERVICES. CENTERS FOR MEDICARE & MEDICAID SERVICES Defendant(s) : ........................... Form Approved OMB No. 0938-0267 INSTRUCTIONS FOR COMPLETING THE COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REQUEST FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM THE filing of this requestSTATE OF NEW YORK the process of obtaining a decision as to whether the Conditions of Participation are (continue The PEOPLE OF THE for certification will initiate to be) met. TO GENERAL INSTRUCTIONS Please answer all questions as of the current date. Return the form to the State agency in the envelope provided; retain a copy for your files. If a return envelope is not provided, the name and address of the State agency may be obtained from the nearest Social Security District Office. GREETINGS: Question I. Identifying Information Question IV. Services Provided Insert the full name under which the CORF operates, its address and WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before telephone number. , the Honorable at the CourtPlease indicate in each block how services are provided, using the following figures: located at County of Medicare/Medicaid provider number - Leave blank on all initial in room , on the day of , 20 , at o'clock in the 1. Employees at any recessed noon, and certifications. On all recertifications, insert the facility's six digit provider 2. the or adjourned date, to testify and give evidence as a witness in this action on the part of Under Arrangement number. 3. Independent Contractor State/County/Region code - Leave blank. CMS Regional Office will complete. These terms are defined below. Note that more than one figure may be used for each block. Blocks #1, #2 and either #3 or #4 must be Your failure to comply with this subpoena is punishable as a contempt of court and will make youeligible to participation since these are completed for the facility to be liable for the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a mandatory services. Question II. Eligibility result of your failure to comply. All applicants are to check block #1 (Medicare). CORF services are covered only under the Medicare program, hence, blocks #2 and #3 Witness, Honorable are for future use only. No entry for related provider number. State Court in will complete.County, day of , 20 agency Question Ill. Type of Control Employee - An individual who is paid a salary per unit time of work (i.e., hourly, yearly), is covered under Social Security and Workmen's , one of the Justices of the Compensation and accrues benefits (i.e., sick leave, vacation). Under Arrangement - The facility has an agreement with an organization to use their personnel. The facility pays the organization and not the individuals providing the services. sign above and type name below) Check the one category that is most descriptive of the type of (Attorney must Independent Contractor - An individual who is paid a sum of money organization operating the facility. Use the following as a guide: based upon services rendered or units of time. However, the independent contractor is not covered under Social Security through the Attorney(s) for facility and does not accrue benefits. The individual generally has Non-profit church - A church affiliated facility governed a contract with the facility. by a board of directors and financed by contributions and earnings. Proprietary - For profit corporation. Non-profit other than church - A facility which is generally governed by a community based board of Office and P.O. Address directors and financed by contributions and earnings. Government - A facility primarily administered by the State, county, city or other local unit of government. Telephone No.: Facsimile No.: 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 E-Mail Address: collection is 0938-0267. The time required to complete this information collection is estimated to average 3 hours per response, including the time to review instructions, search existing data resources, gather the Mobile the No.: data needed, and complete and review the information collection. If you have any comments concerningTel.accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. American LegalNet, Inc. www.USCourtForms.com Defendant(s) : ...................................................... DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0267 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT THE PEOPLE OF THE STATE OF NEW YORK FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM I. IDENTIFYING NAME OF FACILITY TO INFORMATION CITY, COUNTY, STATE (Please read instructions on back before completing form) STREET ADDRESS MEDICARE/MEDICAID PROVIDER NUMBER RD01 ZIP CODE TELEPHONE NO. (Area Code) RD02 STATE/COUNTY RD03 STATE REGION RD04 GREETINGS: II. ELIGIBILITY REQUEST TO ESTABLISH ELIGIBILITY IN: RELATED PROVIDER NUMBER WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before I 1. MEDICARE I 2. MEDICAID I , the Honorable at the 3. BOTH Court RD05 located at County of PROPRIETARY NON-PROFIT GOVERNMENT Does your organization currently participate in Medicare as a provider of Outpatient III. TYPE OF in , on the day of , 20 , at o'clock in the Physical Therapy/Speech Pathology (e.g., Rehabilitation Agency)? noon, and at any recessed CONTROL room I CHURCH (Check one) adjourned date, to testify and give evidence as a witness in this action on the part of the or RD06 I I OTHER RD07 I YES I NO RD08 If yes, list Provider No. ________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to IV. SERVICE PROVIDED: whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the party on Indicate in each block how failure to comply. result of your services are I 1. PHYSICAL THERAPY I 4. PSYCHOLOGICAL SERVICES provided using the following numbers. NOTE: More than one