COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESCalendar No.QIO CASE1. MEDICARE NUMBER2. BENEFICIARYJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)3. NAME OF QIOTELEPHONE NUMBER4. APPELLANT5. DATE OF INITIAL DETERMINATION7. DATE OF HEARING REQUEST//// // 6. DATE OF RECONSIDERATION DETERMINATION8. PROVIDER NAME AND TYPEHOSPITAL SNF HHA OTHERPROVIDER NUMBER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ADDRESSCITYSTATEZIPTHE PEOPLE OF THE STATE OF NEW YORK TO9. ISSUE10. AMOUNT IN CONTROVERSY12. ADMISSION DATE13. DAYS OR VISITS AT ISSUE14. NUMBER15. DATE//// // 11. DATE FORWARDED TO OHA16. INTERMEDIARY NAMEGREETINGS:ADDRESSWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,CITYSTATEZIPlocated 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 room17. CURRENT STATUSSTILL PATIENTDISCHARGEDDIED18. PERTINENT EVIDENCE AND DATESHOSPITAL ADMISSION RECORD HOSPITAL DISCHARGE SUMMARY NURSES NOTES MEDICATION CHARTS DOCTORS ORDERS DOCTORS PROGRESS NOTES PHYSICAL THERAPY NOTES HOSPITAL TO SNF TRANSFER FORM HISTORY AND PHYSICALPHYSICIAN ATTESTATION ELIGIBILITY FORM BILLING FORM CREDENTIALS OF PHYSICIAN RECONSIDERATION REVIEWER RATIONALE FOR DETERMINATION WITH CORRESPONDING STATUTE/REGULATION COPIES OF PRIOR DENIAL/RECONSIDERATION NOTICES (for waiver of liability) COPIES OF CRITERIA/MANUAL PAGES SUPPORTING DECISION, IF NECESSARY OTHER (i.e., M.D. Letters,Consultants Reports, Lab Tests,Graphic Charts, Etc.-PleaseYour 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)Specify)Attorney(s) for19. COMMENTS AND OTHER PERTINENT FACTSOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:A. REPRESENTATIVE ........................................................................................................................................................................ YES NO B. COMPLETED APPOINTMENT OR REPRESENTATIVE FORM.................................................................................................... YES NO Form CMS-384 (3-92)Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com