COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.POST-CERTIFICATION REVISIT REPORTCalendar No.PROVIDER/SUPPLIER/CLIA/IDENTIFICATION NUMBERMULTIPLE CONSTRUCTION A. Building B. Wing Y2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESY1Y3JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)NAME OF FACILITYSTREET ADDRESS, CITY, STATE, ZIP CODE DATE OF REVISITThis report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ITEMDATEITEMDATEITEMDATEY4Y5Y4Y5Y4Y5CorrectionID Prefix CorrectionID Prefix CorrectionTHE PEOPLE OF THE STATE OF NEW YORK TOCompletedReg. # CompletedReg. # Completed//LSC //LSC // ID Prefix Reg. # LSC CorrectionID Prefix CorrectionID Prefix CorrectionID Prefix GREETINGS:CompletedReg. # CompletedReg. # CompletedReg. # WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable//LSC //LSC //LSC ,located at County ofo'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 roomCorrectionID Prefix CorrectionID Prefix CorrectionID Prefix CompletedReg. # CompletedReg. # CompletedReg. # //LSC //LSC //LSC Your 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.CorrectionID Prefix CorrectionID Prefix CorrectionID Prefix CompletedReg. # CompletedReg. # CompletedReg. # , one of the Justices of theCourt in Witness, Honorableday of, 20 County,//LSC //LSC //LSC CorrectionID Prefix CorrectionID Prefix CorrectionID Prefix (Attorney must sign above and type name below)CompletedReg. # CompletedReg. # CompletedReg. # //LSC //LSC //LSC Attorney(s) forREVIEWED BY STATE AGENCY REVIEWED BY (INITIALS)DATESIGNATURE OF SURVEYORDATEOffice and P.O. AddressTITLEDATEREVIEWED BY CMS ROREVIEWED BY (INITIALS)FOLLOWUP TO SURVEY COMPLETED ONTelephone No.: Facsimile No.: E-Mail Address: CHECK (v ) FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NOForm CMS-2567B (9-92)Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com