DEPARTMENT OF HEALTH & HUMAN SERVICES PROVIDER REIMBURSEMENT REVIEW BOARD 2520 Lord Baltimore Drive, Suite L Baltimore, MD 21244-2670 Phone: 410-786-2671 Fax: 410-786-5298 MODEL FORM C ­ REQUEST TO ADD ISSUE(S) TO AN INDIVIDUAL APPEAL Date of Request: _______________________ Individual PRRB Case No.: _______________________ Provider Name: _____________________________________________________ Provider Number: _______________________ Fiscal Year Ended: _______________________ Date of Original Hearing Request: _______________________ A provider may add issues to an appeal provided the request conforms to the requirements of 42 C.F.R. § 405.1835(c). 1. Issue(s) Being Added to Case: _________________________________________________________________________________ _________________________________________________________________________________ UNDER A TAB LABELED 1 YOU MUST SUBMIT A STATEMENT FOR EACH ISSUE BEING ADDED TO THIS APPEAL. The statement of the issue(s) must conform to the requirements of the regulations found at 42 C.F.R. § 405.1835 et seq. and the Board's Rules and must include: (1) a description of the issue; (2) the audit adjustment number(s), if applicable, or other information to demonstrate provider preserved its right to appeal; (3) the amount in controversy; and (4) a statement identifying the legal basis for the appeal (Cite statutes, regulations and/or manual provisions). 2. Does this Request include a request for Expedited Judicial Review? _____ YES _____ NO NOTE: A request for EJR must be submitted in a separate document and "EJR Request" must be marked on the outside of the envelope. 3. Is the Provider requesting Mediation? NOTE: If yes, a request must be submitted in a separate document. 4. Is this issue being transferred concurrently to a group appeal? NOTE: If yes, you must attach Model Form D. _____ YES _____ NO _____ YES _____ NO 5. Representative Information: Are you the representative on file for this individual appeal? _____ YES _____ NO NOTE: If you are not the representative on file or who established this appeal, then you must attach an authorization letter signed by an official of the provider. American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATIONS A. I certify that none of the issues added to this appeal are pending in any other appeal for the same period and provider, nor have they been adjudicated, withdrawn, or dismissed from any other PRRB appeal. Printed Name: _______________________________________________ Title: _______________________________________________ Signature: _______________________________________________ (Provider Owner/Officer/Director or Representative) Date: _______________________ B. I certify to the best of my knowledge that there are no other providers to which this provider is related by common ownership or control that have a pending request for a Board hearing on any of the same issues for a cost reporting period that ends in the same calendar year covered in this request. See, 42 C.F.R. § 405.1835(b)(4)(i). Signature: _______________________________________________ (Provider Owner/Officer/Director or Representative) Date: _______________________ C. I certify that a copy of this Request (and any supporting documentation) was sent by (Check one) _____ United States Postal Service _____ Nationally recognized courier. Specify name: ________________________________ to the Intermediary/MAC on this __________day of ______________, 2_____. Certified Mail or Tracking Number: _________________________________________ Signature: _______________________________________________ (Provider Owner/Officer/Director or Representative) Date: _______________________ American LegalNet, Inc. www.FormsWorkFlow.com