COURT DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. FORM APPROVED OMB No. 0938-0832 : HEALTH INSURANCE BENEFITS AGREEMENT Calendar No. (Agreement with Rural Health Clinic Pursuant to : JUDICIAL Section 1861(aa)(2)(K)(ii) of the Social Security Act) SUBPOENA Plaintiff(s) -against: For the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act, : (Insert name of clinic) : hereafter referred to as the Rural Health Clinic, hereby agrees: Defendant(s) : . .to .maintain compliance. with.the .conditions .for. certification .set. forth. in.part 491 of chapter IV, title 42 of the Code of Federal . .............. ... .. ....... . ......... . ... . (A) Regulations, and to report promptly to the Centers for Medicare & Medicaid Services any failure to do so; (B) not to charge the beneficiary or any other person for items and services for which the beneficiary is entitled to have payment made under the provisions of part 405 of chapter IV, title 42 of the Code of Federal Regulations (or for which the beneficiary THE PEOPLE OF THE STATE OF NEW YORK would have been entitled if the Rural Health Clinic had filed a request for payment in accordance with §410.165 of chapter IV), except for any deductible or coinsurance amounts for which the beneficiary is liable under §405.2410; TO (C) to refund as promptly as possible any money incorrectly collected from a beneficiary or from someone on his or her behalf; (D) to accept beneficiaries for care and treatment without limitations, except as it may impose on all other persons; (E) to accept any additional provisions that the Secretary finds necessary or desirable for the efficient and effective administration GREETINGS: program. of the Medicare WE COMMAND YOU, that Health Clinic and upon acceptance for filing by the Secretary you attend Human This agreement, upon submission by the Ruralall business and excuses being laid aside, you and each ofof Health andbefore , the Honorable at the Court Services, shall be binding on the Rural Health Clinic and the Secretary. The agreement may be terminated by either party in accordance with regulations. In the eventlocated at of termination, payment will not be available for Rural Health Clinic services furnished on County of or after the effective date on termination. of in room , of the day , 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 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, the agreement is automatically assignedato the new owner subject to the conditionsliable to Your failure to comply with this subpoena is punishable as contempt of court and will make you specified in this agreement whose CFR 489, to subpoena was issued for a maximum penalty ofof thisand all damages agreement is a the party on and 42 behalf this include existing plans of correction and the duration $50 agreement, if the sustained as time limited. your failure to comply. result of 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, Court in County, day of , 20 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). (Attorney must sign above and type name below) Witness, Honorable , one of the Justices of the Accepted for Rural Health Clinic by: NAME (SIGNATURE) TITLE DATE Accepted for the Secretary of Health and Human Services by: NAME (SIGNATURE) Attorney(s) for TITLE DATE Office and P.O. Address 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 0938-0832. 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 Telephone No.: suggestions for improving this form, please write to CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850. Facsimile No.: E-Mail Address: Mobile Tel. No.: Form CMS-1561A (4-02) Previous version obsolete American LegalNet, Inc. www.USCourtForms.com