DEPARTMENT OF HEALTH AND HUMAN SERVICES COUNTY OF CENTERS FOR MEDICARE & MEDICAID SERVICES COURT ...................................................... Index No. HEALTH INSURANCE BENEFIT: AGREEMENT (Agreement with Provider Pursuant to Section 1866 of the Social Security Act, : Calendar No. as Amended and Title 42 Code of Federal Regulations (CFR) Chapter IV, Part 489) FORM APPROVED OMB No. 0938-0832 Plaintiff(s) AGREEMENT -against- : JUDICIAL SUBPOENA between : THE SECRETARY OF HEALTH AND HUMAN SERVICES and : __________________________________________________ : doing business as (D/B/A) ____________________________ : In order .to .receive payment. under .title. XVIII.of.the .Social .Security. Act,_________________________________________________ ... . ........... .... .. .... . .. .... ..... ....... ___________________________________________________________________________________________________________ D/B/A ___________________________________________________________________ as the provider of services, agrees to conform to the provisions of section of 1866 of the Social Security Act and applicable provisions in 42 CFR. This agreement, upon submission by the provider of services of acceptable assurance of compliance with title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973 as amended, and upon acceptance by the Secretary of Health and Human TO Services, shall be binding on the provider of services and the Secretary. In the event of a transfer of ownership, this agreement is automatically assigned to the new owner subject to the conditions specified in this agreement and 42 CFR 489, to include existing plans of correction and the duration of this agreement, if the agreement is time limited. GREETINGS: ATTENTION:WE COMMAND YOU, that all business carefully before signing. aside, you and each of you attend before Read the following provision of Federal law and excuses being laid Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, located at County of conceals or covers up by any trick, scheme or device a material fact, or make any false, fictitious or fraudulent statement or in room on the day of , 20 , at representation, or makes ,or uses any false writing or document knowing the sameo'clock in any false,noon, and at any recessed to contain the fictitious or fraudulent statement or entry, date, to testify and give evidence as aimprisoned not more than 5 the part both (18 U.S.C. section 1001). or adjourned shall be fined not more than $10,000 or witness in this action on years or of the Name __________________________________ Date __________________________________ Title __________________________________ Defendant(s) THE PEOPLE OF THE STATE OF NEW YORK the Honorable at the Court , Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party FOR THE PROVIDERsubpoena was issued for a maximum penalty of $50 and all damages sustained as a ACCEPTED on whose behalf this OF SERVICES BY: result of your failure to comply. NAME (signature) TITLE Court in Witness, Honorable County, day of , 20 DATE , one of the Justices of the ACCEPTED BY THE SECRETARY OF HEALTH AND HUMAN SERVICES BY: NAME (signature) (Attorney must sign above and type name below) DATE TITLE Attorney(s) for ACCEPTED FOR THE SUCCESSOR PROVIDER OF SERVICES BY: NAME (signature) TITLE Office and P.O. Address 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 0MB control number. The valid Telephone No.: 0MB control number for this information collection is 0938-0832. The time required to complete this information collection is estimated to average 5 minutes per response, Facsimile No.: including the time to review instructions, search 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 estimate(s) or suggestions for improving this form, please writeE-Mail Address: to CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850. Mobile Tel. No.: Form CMS-1561 (7/01) Previous Version Obsolete American LegalNet, Inc. www.USCourtForms.com