DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB No. 0938-0266 HEALTH INSURANCE BENEFITS AGREEMENT (AGREEMENT WITH AMBULATORY SURGICAL CENTER PURSUANT TO SECTION 1832(a)(2)(F) OF THE SOCIAL SECURITY ACT) For the purpose of establishing eligibility for payment under title XVIII of the Social Security Act, (Insert Name of Facility) hereinafter referred to as the Ambulatory Surgical Center, hereby agrees: (A) to maintain compliance with the conditions set forth in part 416 of chapter IV, title 42 of the Code of Federal Regulations, and to report promptly to the Centers for Medicare & Medicaid Services (CMS) any failure to do so; (B) not to charge a Medicare beneficiary or any other person for items or services for which the beneficiary is entitled to have payment made in accordance with part 416 of chapter IV, title 42 of the Code of Federal Regulations; (C) to refund as promptly as possible any money incorrectly collected from beneficiaries or from someone on his or her behalf; (D) to furnish to CMS, if requested, information necessary to establish payment rates specified in §416.120 and §416.130 in the form and manner that CMS requires; (E) to accept assignment for all facility services furnished in connection with covered surgical procedures as specified in §416.85; and (F) to comply with statutory and regulatory requirements regarding revision of the Quality Improvement Organization that contracts with CMS to review ambulatory surgical procedures. This agreement, upon submission by the Ambulatory Surgical Center and upon acceptance for filing by the Secretary of Health and Human Services, shall be binding on the Ambulatory Surgical Center and the Secretary. The agreement may be terminated by either party in accordance with regulations. In the event of termination, payment will not be available for Ambulatory Surgical Center services furnished on or after the effective date of termination. This agreement shall become effective on the date specified below by the Secretary or the Secretary's delegate, and shall remain in effect unless terminated. In the event of a transfer of ownership of the Ambulatory Surgical Center, this Agreement Shall Remain Effective as between the Secretary of Health and Human Services and the Transferee. ATTENTION: Read the following provision of Federal law carefully before signing. Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or make any false, fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement, or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both (18 U.S.C. section 1001). Accepted for the Ambulatory Surgical Center by: NAME (SIGNATURE) TITLE DATE EFFECTIVE DATE OF AGREEMENT Accepted for the Secretary of Health and Human Services by: NAME (SIGNATURE) TITLE 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 0938-0266. The time required to complete this information collection is estimated to average 5 minutes per response, 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 write to CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850. Form CMS-370 (4-02) American LegalNet, Inc. www.USCourtForms.com