COURT COUNTY OFFORM APPROVED OMB No. 0938-0193 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.2. STATE1. TRANSMITTAL NUMBERTRANSMITTAL AND NOTICE OF APPROVAL OFCalendar No.STATE PLAN MATERIAL3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIALFOR: CENTERS FOR MEDICARE & MEDICAID SERVICESSECURITY ACT (MEDICAID)JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATORCENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One)NEW STATE PLANAMENDMENT TO BE CONSIDERED AS NEW PLANAMENDMENTCOMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. FEDERAL STATUTE/REGULATION CITATION7. FEDERAL BUDGET IMPACTa. FFY $ b. FFY $ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTIONTHE PEOPLE OF THE STATE OF NEW YORK TOOR ATTACHMENT (If Applicable)GREETINGS:10. SUBJECT OF AMENDMENTWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of11. GOVERNOR'S REVIEW (Check One)o'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 roomOTHER, AS SPECIFIEDGOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL16. RETURN TO12. SIGNATURE OF STATE AGENCY OFFICIALYour 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.13. TYPED NAME, one of the Justices of the14. TITLECourt in Witness, Honorableday of, 20 County,15. DATE SUBMITTEDFOR REGIONAL OFFICE USE ONLY(Attorney must sign above and type name below)17. DATE RECEIVED18. DATE APPROVEDPLAN APPROVED -ONE COPY ATTACHED19. EFFECTIVE DATE OF APPROVED MATERIAL20. SIGNATURE OF REGIONAL OFFICIALAttorney(s) for21. TYPED NAME22. TITLEOffice and P.O. Address23. REMARKSTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:Instructions on BackFORM CMS-179 (07/92)American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.INSTRUCTIONS FOR COMPLETING FORM CMS-179Calendar No.Use Form CMS-179 to transmit State plan material to the regional office for approval. A separate typed transmittal form should be completed for each plan/amendment submitted.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Block 1 -Transmittal Number -Enter the State Plan Amendment transmittal number. Assign consecutive numbers on a calendar year basis (e.g., 92-001, 92-002, etc.). Block 2 -State -Type the name of the State submitting the plan material. Block 3 -Program Identification -Title XIX of the Social Security Act (Medicaid). Block 4 -Proposed Effective Date -Enter the proposed effective date of material. Block 5 -Type of Plan Material -Check the appropriate box. Block 6 -Federal Statute/Regulation Citation -Enter the appropriate statutory/regulatory citation. Block 7 -Federal Budget Impact -7(a) -Enter 1st Federal Fiscal Year (FFY) impacted by the SPA & estimated Federal share of the cost of the SPA (in thousands) for 1st FFY.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TO7(b) -Enter 2nd FFY impacted by the SPA & estimated Federal share of the cost for 2nd FFY. See SMM section 13026.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,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 roomYour 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)Attorney(s) forBlock 8 -Page No.(s) of Plan Section or Attachment -Enter the page number(s) of plan material transmitted. If additional space is needed, use bond paper. Block 9 -Page No.(s) of the Superseded Plan Section or Attachment (if Applicable) -Enter the page number(s) (including the transmittal sheet number) that is being superseded. If additional space is needed, use bond paper. Block 10 -Subject of Amendment -Briefly describe plan material being transmitted. Block 11 -Governor's Review -Check the appropriate box. See SMM section 13026 B. Block 12 -Signature of State Agency Official -Authorized State official signs this block. Block 13 -Typed Name -Type name of State official who signed block 12. Block 14 -Title -Type title of State official who signed block 12. Block 15 -Date Submitted -Enter the date you mail plan material to RO. Block 16 -Return To -Type the name and address of State official to whom this form should be returned. Block 17 23 (FOR REGIONAL OFFICE USE ONLY). Block 17 -Date Received -Enter the date plan material is received in RO. See ROM section 6003.2. Block 18 -Date Approved -Enter the date RO approved the plan material. Block 19 -Effective Date of Approved Material -Enter the date the plan material becomes effective. If more than one effective date, list each provision and its effective date in Block 23 or attach a sheet. Block 20 -Signature of Regional Official -Approving RO official signs this block. Block 21 -Typed Name -Type approving official's name. Block 22 -Title -Type approving official's title. Block 23 -Remarks -Use this block to reference pen and ink changes, a partial approval, more than one effective date, etc. If additional space is needed, use bond paper. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection