DEPARTMENTOF HEALTH AND HUMAN SERVICES Form Approved CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0952 REQUEST FOR SECTION 1011 HOSPITAL ON-CALLPAYMENTS TO PHYSICIANS PROVIDER NUMBER ON-CALLPERIOD TO FROM PART I 1. Section 1011 (c)(3)(C)(ii) of MMA2003 provides for the election by a hospital for a portion of the on-cal l payments made by the hospital to physicians. If your hospital made the e lection under section 1011(c)(3)(C)(ii), check Yes and complete the entire form. If No you are not eligible to claim on-call payments made to physicians.o Yes o No PART II IDENTIFICATION DATA 2. NAME OF HOSPITAL 3. STREETADDRESS P.O.BOX 4. CITY STATE ZIP CODE COUNTY PART III CALCULATION SUMMARY ON-CALL CALCULATION 5. Enter the charges made by the hospital for providing Emergency Department services to individuals identified in section 1011(c)(5) (see instructions). 6. Enter the total charges made by a hospital for providing Emergency Department services to all patients (see instructions). 7. Apportionment ratio (Line 5 divided by line 6). 8. Total On-Call Costs (see instructions). 9. On-Call Payment Amount (Line 7 times Line 8). PART IV CERTIFICA TION Misrepresentation or falsification of any information contained in this report may be punishable by criminal, civil and administrative action, fine and/or imprisonment under Federal Law. Furthermore, if services identified in this report were provided or procured through the payment directly or indirectly of a kickback or where otherwise illegal, criminal, civil and administrative action, fines and/ or imprisonment may result. A hospital receiving Section 1011 payments (hereinafter payee) acknowledges that those payment s may be retroactively adjusted at the end of each fiscal year in accordance with subsection (c)(2) of Section 1011. If CMS determines that payments must be retroactively adjusted, the payee a grees that it will promptly remit the full amount of the reduction to CMS in accordance with instructions prov ided with the Notice of Retroactive Adjustment. Payee acknowledges that there will be no appeal or review of the determination of retroactive adjustment. Any payment owed to CMS must be remitted promptly, but in no event later than 30 days after notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of infor mation unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0952. The time required to complete this information collection is estimated t o average 45 minutes per response, including the time to review instruct ions, search existing data resources, gather the data needed, and complete and review the informati on collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRAReports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-10130B (05/05) EF (05/2005) 1 American LegalNet, Inc. www.USCourtForms.com>>>> 2 CERTIFICATION BYOFFICER OR ADMINISTRATOR OF PROVIDER(S) I HEREBYCERTIFY that I have read the above statement and that I have examined the manual ly submitted report by ______________________________________________________ (Prov ider Name(s) and Number(s)) for the reporting period beginning __________________ and ending ___________________ and that to the best of my knowledge and belief, it is a true, correct and c omplete statement prepared from the books and records of the provider in accordance with applicable instruct ions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services and that the services identified in this report were provided in compliance with such laws and regulations. (Signed) ____________________________________________ Office or Administrator of Provider(s) ____________________________________________ Title ____________________________________________ Date Form CMS-10130B (05/05) EF (05/2005) 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 INSTRUCTIONS FOR COMPLETING THE REQUEST FOR SECTION 1011 HOSPITAL ON-CALLPAYMENTS TO PHYSICIANS FORM PART I LINE 1 If the hospital made the election under section 1011(c)(3)(C)(ii) of the Medicare Modernization Act of 2003 to seek payment for a portion of on-call payments made to physicians, check Yes, and complete all parts of this form. If the response is No, your facility is not eligible to claim on-call p ayments made to physicians. PART II IDENTIFICATION DATA The information required in this section is needed to properly identify the provider. LINE 2 Enter the hospital name. LINE 3 Enter the street address and P.O. Box (if applicable) for the facility. LINE 4 Enter the city, state, ZIPcode, and county information for the facility. PART III CALCULATION SUMMARY Part III determines the allowable on-call costs for emergency health services furnished to section 1011(c)(5) individuals by apportioning costs on the basis of applying the ratio of Emergency Department charges for section 1011(c)(5) individuals divided by total Emergency Department charges for the entire hospital multiplied by the total Emergency Department costs for the entire hospital. This calculation is applied on a Federal fiscal quarterly basis. LINE 5 Enter from your accounting books and/or records the charges recorded by the hospital for providing Emergency Department services to individuals identified in section 1011(c)(5) of MMA2003 during the quarter. LINE 6 Enter from your accounting books and/or records the total charges recorded by the hospital for providing Emergency Department services to all patients during the quarter. LINE 7 Determine the apportionment ratio by dividing the amount on line 5 by th e amount on line 6. Round the result to six decimal places. LINE 8 Enter from your accounting books and/or records the total cost for on-ca ll physician services furnished to all patients during the quarter. LINE 9 Determine the allowable on-call payment amount claimed by multiplying th e ratio on line 7 times the amount on line 8 and enter the result. PART IV CERTIFICATION BYOFFICER OR ADMINISTRATOR OF PROVIDER(S) This certification is read, prepared, and signed after the cost statemen t has been completed in its entirety. The cost statement will not be accepted by the contractor unless it contains