COURT COUNTY .HEALTH.AND.HUMAN.SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . OF. . . . . . . . . . . . . . DEPARTMENT OF ......... .. CENTERS FOR MEDICARE & MEDICAID SERVICES : Medical Insurance Benefits - Social Security Act REQUEST FOR HEARING PART B MEDICARE :CLAIM Calendar No. Index No. Form Approved OMB No. 0938-0034 NOTICE--Anyone who misrepresents or falsifies essential information requested by this form may upon conviction : be subject to fine and imprisonment under JUDICIAL SUBPOENA Federal Law. Plaintiff(s) CARRIER'S NAME AND ADDRESS -against- 1 2 NAME OF PATIENT : HEALTH INSURANCE CLAIM NUMBER : : my claim, and 3 I disagree with the review determination on Defendant(s) request a hearing before a hearing officer of the : . . insurance . . . . . . named. above.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . carrier . . . . . . . . . . MY REASONS ARE: (Attach a copy of the Review Notice. NOTE: If the review decision was made more than 6 months ago, include your reason for not making this request earlier.) THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: 4 WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before CHECK ONE CHECK ONLY ONE OF THE STATEMENTS BELOW: , the HonorableOF THE FOLLOWING at the Court located at CountyI of additional evidence to submit. I have I I wish to appear in person before the in room on the day of , 20 , at o'clock in the noon, and at any recessed Hearing Officer. (Attach such ,evidence to this form or or adjourned date, thetestify and give days.) to carrier within 10 evidence as a witness in this action on the part of the forward it to I I I do not have additional evidence. I do not wish to appear and hereby request a decision on the evidence before the Hearing Officer. 5 EITHERYour failure to complyREPRESENTATIVE is punishable as a contempt of court and will make you liable to THE CLAIMANT OR with this subpoena SHOULD SIGN IN THE APPROPRIATE SPACE BELOW the party on NAME behalf this subpoena was issued for SIGNATURE OR whose OF CLAIMANT'S REPRESENTATIVE result of your failure to comply. ADDRESS a CLAIMANT'S SIGNATURE and all damages sustained as a maximum penalty of $50 Witness, Honorable Court in County, ADDRESS , one of the Justices of the day of , 20 CITY, STATE, AND ZIP CODE (Attorney must sign above and type name below) DATE TELEPHONE NUMBER CITY, STATE, AND ZIP CODE TELEPHONE NUMBER DATE (Claimant should not write below this line) Attorney(s) for ACKNOWLEDGMENT OF REQUEST FOR HEARING Office and P.O. Address Your request for a hearing was received on ____________________________________________ . You will be notified of the time and place of the hearing at least 10 days before the date of the hearing. SIGNED Telephone No.: Facsimile No.: DATE E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com Form CMS-1965 (05/03) COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) Index No. Calendar No. COLLECTION AND USE OF MEDICARE INFORMATION : JUDICIAL SUBPOENA We are authorized by the Centers for -against- & Medicaid Services to ask you:for information needed in the administration of the Medicare Medicare program. Authority to collect information is in section 205 (a), 1872 and 1875 of the Social Security Act, as amended. : The information we obtain to complete your Medicare claim is used to identify you and to determine your eligibility. It also is used to decide if the services and supplies you received are covered by Medicare and: to insure that proper payment is made. Defendant(s) The information may also be given to other providers of services, carriers, intermediaries, medical review boards, and other : ..... . ...... . ....... .. ...... ......... ........ organizations .as .necessary. to. administer. the.Medicare. program. For. example, it .may be necessary to disclose information about the Medicare benefits you have used to a hospital or doctor. With one exception, which is discussed below, there are no penalties under Social Security law for refusing to supply information. THE PEOPLE OF THE STATE OF NEW YORK However, failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of the claim. Failure to furnish any other information, such as name or claim number, would delay payment of the claim. TO It is mandatory that you tell us if you are being treated for a work related injury so we can determine whether workmen's compensation will pay for the treatment. Section 1877(a)(3) of the Social Security Act provides criminal penalties for withholding this information. GREETINGS: WE COMMAND YOU, that persons are required to respond to a collection of information each of you attend OMB According to the Paperwork Reduction Act of 1995, no all business and excuses being laid aside, you andunless it displays a valid before at 0938-0034. The time required to complete this information collection is Court control the Honorable OMB number for this information collection isthe number. The valid estimated to average 10 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, located at County of and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for in room , on the day of , 20 , at o'clock in the noon, and at any recessed improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. or adjourned date, to testify and give evidence as a witness in this action on the part of the , 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. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com