COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESCalendar No.UPDATED PLAN OF PROGRESS FOR OUTPATIENT REHABILITATION(Complete for Interim to Discharge Claims. Photocopy of CMS-700 or 701 is required.)1. PATIENT'S LAST NAMEFIRST NAMEM.I.2. PROVIDER NO.3. HICNJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)4. PROVIDER NAME5. MEDICAL RECORD NO. (Optional)6. ONSET DATE7. SOC. DATE8. TYPE9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC.PTOTSLPCRRTPSSNSW 12. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.)13. CURRENT PLAN UPDATE, FUNCTIONAL GOALS (Specify changes to goals and plan.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GOALS (Short Term)PLANTHE PEOPLE OF THE STATE OF NEW YORK TOOUTCOME (Long Term)GREETINGS:I HAVE REVIEWED THIS PLAN OF TREATMENT AND14. RECERTIFICATIONWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableRECERTIFY A CONTINUING NEED FOR SERVICES.N/ADCFROMTHROUGHN/A,15. PHYSICIAN'S SIGNATURE16. DATE17. ON FILE (Print/type physician's name)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 room18. REASON(S) FOR CONTINUING TREATMENT THIS BILLING PERIOD (Clarify goals and necessity for continued skilled care.)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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) for19. SIGNATURE (or name of professional, including prof. designation) 20. DATE21.DC SERVICESCONTINUE SERVICES OR22. FUNCTIONAL LEVEL (At end of billing period Relate your documentation to functional outcomes and list problems still present.)Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:22. SERVICE DATESMobile Tel. No.:THROUGHFROMForm CMS-701(11-91)American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .INSTRUCTIONS FOR COMPLETION OF FORM CMS-701:::::::Index No.(Enter dates as 6 digits, month, day, year)Calendar No.14. Recertification -Enter the inclusive dates when recertification1. Patient's Name -Enter the patient's last name, first name andis required, even if the ON FILE box is checked in item 17. Check the N/A box if recertification is not required for the type of service rendered.middle initial as shown on the health insurance Medicare card.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)2. Provider Number -Enter the number issued by Medicare tothe billing provider (i.e., 00 7000).15. Physician's Signature -If the form CMS-701 is used for3. HICN -Enter the patient's health insurance number as shownrecertification, the physician enters his/her signature. If recertification is not required for the type of service rendered, check N/A box. If the form CMS-701 is not being used for recertification, check the ON FILE box -item 17. If discharge is ordered, check DC box.on the health insurance Medicare card, certification award, utilization notice, temporary eligibility notice, or as reported by SSO.4. Provider Name -Enter the name of the Medicare billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .provider.16. Date -Enter the date of the physician's signature only if theform is used for recertification.5. Medical Record No. -(optional) Enter the patient's medical/clinical record number used by the billing provider. (This is an item which you may enter for your own records.)17. On File (Means certification signature and date) -Enter thetyped/printed name of the physician who certified the plan of treatment that is on file at the billing provider. If recertification is not required for the type of service checked in item 8, type/print the name of the physician who referred or ordered the service, but do not check the ON FILE box.THE PEOPLE OF THE STATE OF NEW YORK TO6. Onset Date -Enter the date of onset for the patient's primarymedical diagnosis, if it is a new diagnosis, or the date of the most recent exacerbation of a previous diagnosis. If the exact date is not known enter 01 for the day (i.e., 120191). The date matches occurrence code 11 on the UB-92.18. Reason(s) For Continuing Treatment This Billing Period -Enter the major reasons why the patient needs to continueGREETINGS:7. SOC (start of care) Date -Enter the date services began atskilled rehabilitation for this billing period (e.g., briefly state the patient's need for specific functional improvement, skilled training, reduction in complication or improvement in safety and how long you believe this will take, if possible or state your reasons for recommending discontinuance). Complete by the rehab specialist prior to physician's recertification.the billing provider (the date of the first Medicare billable visit which remains the same on subsequent claims until discharge or denial corresponds to occurrence code 35 for PT, 44 for OT, 45 for SLP and 46 for CR on the UB-92).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 room8. Type -Check the type therapy billed; i.e., physical therapy(PT), occupational therapy (OT), speech-language pathology (SLP), cardiac rehabilitation (CR), respiratory therapy (RT), psychological services (PS), skilled nursing services (SN), or social services (SW).19. Signature -Enter the signature (or name) and the professionaldesignation of the individual justifying or recommending need for care (or discontinuance) for this billing period.20. Date -Enter the date of the rehabilitation professional'sYour failure to comply with this subpoena is punishable as a contempt of court and will make you l