Consent For Home Visit For Pace Services Evaluation {CMS-36P}

GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed P (7/02)) 7/22/02 12:31 PM Page 1 or adjourned date, to testify and give evidence as a witness in this action on the part of the Form CMS-36 Your failure to comply DEPARTMENT OF HEALTH AND HUMAN SERVICES with this subpoena is punishable as a contempt the party on & MEDICAID SERVICES CENTERS FOR MEDICARE whose behalf this subpoena was issued for a maximum penalty of result of your failure to comply. Witness, Honorable BENEFICIARY NAME Court in County, of court and will make you liable to $50 and all damages sustained as a CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION ADDRESS , one of the Justices of the , 20 day of (Attorney must sign above and type name below) By this document, I hereby consent to have State/Federal health review personnel conduct a home visit to ensure that the Federal requirements are met and to assist in Attorney(s) for effectiveness and quality of evaluating the home health services that I receive from the _______________________________________________. (Name of PACE Organization) I understand that consent for this visit is voluntary and none of my rights to Address Office and P.O. confidentiality or privacy are waived by my consent. I have been told and I understand that refusal to consent to a home health visit will have no effect on the level or nature of PACE benefits I am currently receiving. Telephone No.: BENEFICIARY, OR REPRESENTATIVE OF THE BENEFICIARY, SIGNATURE Facsimile No.: DATE E-Mail Address: Mobile Tel. No.: Form CMS-36 P (7/02) American LegalNet, Inc. www.USCourtForms.com I