COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESCalendar No.PLAN OF TREATMENT FOR OUTPATIENT REHABILITATION(COMPLETE FOR INITIAL CLAIMS ONLY)JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)1. PATIENT'S LAST NAMEFIRST NAMEM.I.2. PROVIDER NO.3. HICN4. PROVIDER NAME5. MEDICAL RECORD NO. (Optional)6. ONSET DATE7. SOC. DATE8. TYPE9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC.PTOTSLPCRRTPSSNSW12. PLAN OF TREATMENT FUNCTIONAL GOALSPLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GOALS (Short Term)THE PEOPLE OF THE STATE OF NEW YORK TOOUTCOME (Long Term)GREETINGS:13. SIGNATURE (professional establishing POC including prof. designation)14. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableI CERTIFY THE NEED FOR THESE SERVICES FURNISHED UNDER17. CERTIFICATION,THIS PLAN OF TREATMENT AND WHILE UNDER MY CAREN/Alocated at County ofFROMTHROUGHN/A 15. PHYSICIAN SIGNATURE16. DATEo'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 room18. ON FILE (Print/type physician's name)20. INITIAL ASSESSMENT (History, medical complications, level of function19. PRIOR HOSPITALIZATION at start of care. Reason for referral.)FROMN/ATOYour 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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) for21. FUNCTIONAL LEVEL (End of billing period) PROGRESS REPORTDC SERVICESCONTINUE SERVICES OROffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:22. SERVICE DATESMobile Tel. No.:THROUGHFROMForm CMS-700-(11-91)American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.INSTRUCTIONS FOR COMPLETION OF FORM CMS-700Calendar No.(Enter dates as 6 digits, month, day, year)JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)1. Patient's Name -Enter the patient's last name, first namegoals and outcome. Estimate time-frames to reach goals, when possible.and middle initial as shown on the health insurance Medicare card.13. Signature -Enter the signature (or name) and the2. Provider Number -Enter the number issued by Medicare toprofessional designation of the professional establishing the plan of treatment.the billing provider (i.e., 00 7000).3. HICN -Enter the patient's health insurance number as shown14. Frequency/Duration -Enter the current frequency andon the health insurance Medicare card, certification award, utilization notice, temporary eligibility notice, or as reported by SSO.duration of your treatment; e.g., 3 times per week for 4 weeks is entered 3/Wk x 4Wk.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15. Physician's Signature -If the form CMS-700 is used for4. Provider Name -Enter the name of the Medicare billingcertification, the physician enters his/her signature. If certification is required and the form is not being used for certification, check the ON FILE box in item 18. If the certification is not required for the type service rendered,THE PEOPLE OF THE STATE OF NEW YORK TOprovider.5. Medical Record No. -(optional) Enter the patient's medical/clinical record number used by the billing provider.check the N/A box.6. Onset Date -Enter the date of onset for the patient's primary16. Date -Enter the date of the physician's signature only if themedical diagnosis, if it is a new diagnosis, or the date of the most recent exacerbation of a previous diagnosis. If the exact date is not known enter 01 for the day (i.e., 120191). The date matches occurrence code 11 on the UB-92.form is used for certification.GREETINGS:17. Certification -Enter the inclusive dates of the certification,even if the ON FILE box is checked in item 18. Check the N/A box if certification is not required.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable7. SOC (start of care) Date -Enter the date services began at,the billing provider (the date of the first Medicare billable visit which remains the same on subsequent claims until discharge or denial corresponds to occurrence code 35 for PT, 44 for OT, 45 for SLP and 46 for CR on the UB-92).18. ON FILE (Means certification signature and date) -Enter thelocated at County oftyped/printed name of the physician who certified the plan of treatment that is on file at the billing provider. If certification is not required for the type of service checked in item 8, type/print the name of the physician who referred or ordered the service, but do not check the ON FILE box.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 room8. Type -Check the type therapy billed; i.e., physical therapy(PT), occupational therapy (OT), speech-language pathology (SLP), cardiac rehabilitation (CR), respiratory therapy (RT), psychological services (PS), skilled nursing services (SN), or social services (SW).19. Prior Hospitalization -Enter the inclusive dates of recentYour 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.hospitalization (1st to DC day) pertinent to the patient's current plan of treatment. Enter N/A if the hospital stay does not relate to the rehabilitation being rendered.9. Primary Diagnosis -Enter the pertinent written medicaldiagnosis resulting in the therapy disorder and relating to 50% or more of effort in the plan of treatment.20. Initial Assessment -Enter only current relevant history, one of the Justices of thefrom records or