COURT DEPARTMENT OF HEALTH AND HUMAN SERVICES COUNTY OF . . . . . . . & MEDICAID . . . . . . CENTERS FOR MEDICARE . . . . . . . . SERVICES. ................................ : Form Approved OMB No. 0938-0008 No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 405.1678). NOTICE -- Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal law. : MEDICAL INSURANCE BENEFITS--SOCIAL SECURITY ACT (See Instructions on Back--Type or Print Information) Calendar No. Plaintiff(s) 1. Name of Patient -against: : 3. Claim Number (Copy from Patient's Medicare Card) REQUEST FOR MEDICARE PAYMENT BY ORGANIZATIONS WHICH QUALIFY TO RECEIVE PAYMENT FOR PAID BILLS Index No. JUDICIAL SUBPOENA 2. Male Female 4. Telephone Number : 5. Street Address, City, State, ZIP Code : PART I ­ CLAIMS INFORMATION complete Part II below.) : 6. Describe the . . . . . .or . . . . .for which.the .patient. received .treatment. . . . . . .fill .in this item if the doctor does not . . illness . injury . . . . . . . . . . . . . . . . . . . . . . . . . (Always . . . . Defendant(s) 7. Was patient's illness or injury connected with his employment? Yes No 8. I requestTHE PEOPLE OF THE STATEof ____________________________________________________________________ payment of SMI benefits on behalf OF NEW YORK (Name and address of organization) TO hereinafter referred to as "the organization," in accordance with approval # ________________. I certify in connection with this request that the patient named above has been furnished the services described in this claim, and that the organization: a. has paid in full the amount of the charges for the services shown in this claim; b. has the patient's written authorization to receive SMI benefits due on the basis of bills paid in full by the organization; GREETINGS: c. relieves the patient of liability for payment of the services specified in this claim, and will not seek any reimbursement from him with respect to such services, if an SMI benefit is paid to the organization on this claim. 9. Signature of Organization Representative the Honorable 10. A. Date of each service WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Title Date , at the Court located atOR SUPPLIER TO FILL IN 7 THROUGH 14 County of PART II ­ PHYSICIAN inB. room , on the , 20 , at o'clock in the noon, and at any recessed C. day of D. E. Charges Fully date, surgical or medical procedures and other services Nature of the part Place of Leave or adjourneddescribe to testify and give evidence as a witness in this action on illness or of the (If related to unusual or supplies furnished for each date given (If Lab Service, injury requiring services service indicate if automated) (*See codes below) Procedure Code or supplies circumstances explain in 10C) Blank $ 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) 11. Name and address (Number and Street, City, State, ZIP Code) of physician or supplier 12. Total $ charges Attorney(s) for Amount 13. $ paid Physician or supplier code 14. Any unpaid $ balance due 15. Show name and address of facility where services were performed Telephone Number Office and P.O. Address (Complete if outside your own office or patient's residence) 16. Signature of physician or supplier (I certify that the statements under Physicians' Notes on the reverse apply to Telephone No.: this bill and are made a part hereof.) * O Doctor's Office IL Independent Laboratory FORM CMS-1490U (2) (01/01) Date signed Facsimile No.: E-Mail Address: H Patient's Home (If portable X-ray services, identify the supplier) SNF Skilled Nursing Facility IH Inpatient Hospital OH Outpatient Mobile Tel. No.: Hospital OL Other Locations NH Nursing Home American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. 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 : Index No. number. The valid OMB number for this information collection is 0938-0008. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, searching 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 suggestions for improving this form, please Calendar No. write to: CMS, Mailstop N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Plaintiff(s) -against- : : : JUDICIAL SUBPOENA MAILING INSTRUCTIONS INSTRUCTIONS--PLEASE READ BEFORE COMPLETING THE OTHER SIDE OF THIS FORM INSTRUCTIONS TO THE ORGANIZATION An authorized representative of the organization should enter the patient's Mail this form to the carrier handling medical insurance benefits in the name, health insurance claim number, address, and sex in the appropriate area where the medical services or items were furnished. The nearest : blocks. The representative should complete item 6 in all cases if Part II is Social Security office will be glad to help anyone who calls, writes, or not completed and check the appropriate box. The representative should telephones for assistance in filing his claim. If it is more convenient, you Defendant(s) get help :from the carrier designated to handle medical insurance enter the organization's name and assigned number in the spaces provided may . . . . . . . . in . . . 9 . . . . . . . . . . . . . . . . . . . ....... . in item 8 and sign the.form . . item . .including his/her. title. and.the date.. . . . . . .benefits for .your area. The form serves as a paid bill when the physician completes Part II. If itemized bills are attached, THEY MUST SHOW: FOR MORE INFORMATION If you have a question about the way a particular claim was handled, you should get in touch with the carrier which made the payment or with the nearest Social