Last updated: 4/3/2007
Medicare Credit Balance Report Certification Page {CMS-838}
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<document>COURT COUNTY OFDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESForm Approved. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Form Approved OMB No. 0938-0600 DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB No. 0938-0600:::::::Index No.Calendar No.MEDICARE CREDIT BALANCE REPORTCERTIFICATION PAGEJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)The Medicare Credit Balance Report is required under the authority of sections 1815(a), 1833(e), 1886(a)(1)(C) and related provisions of the Social Security Act. Failure to submit this report may result in a suspension of payments under the Medicare program and may affect your eligibility to participate in the Medicare program.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ANYONE WHO MISREPRESENTS, FALSIFIES, CONCEALS OR OMITS ANY ESSENTIAL INFORMATION MAY BE SUBJECT TO FINE, IMPRISONMENT OR CIVIL MONEY PENALTIES UNDER APPLICABLE FEDERAL LAWS.THE PEOPLE OF THE STATE OF NEW YORK TOCERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDERI HEREBY CERTIFY that I have read the above statements and that I have examined the accompanying credit balance report prepared byGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable, Provider NameProvider 6-Digit Numberlocated 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 roomfor the calendar quarter endedand that it is a true, correct, and complete statement prepared from the books and records of the provider in accordance with applicable Federal laws, regulations and instructions.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.(Sign) Officer or Administrator of Provider, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Print) Name and Title(Attorney must sign above and type name below)(Print) DateAttorney(s) forCHECK ONE: Qualify as a Low Utilization Provider. The Credit Balance Report Detail Page(s) is attached. There are no Medicare credit balances to report for this quarter. (No Detail Page(s) attached.)Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address: Contact PersonTelephone NumberMobile Tel. No.:Form CMS-838 (10/03)Form CMS-838 (10/03)INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT -PROVIDER INSTRUCTIONS, FORM CMS-838American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Approved0600Calendar No.0938-FormNo.JUDICIAL SUBPOENAAddress)Plaintiff(s) -against-Defendant(s)OMBPayer15)-(Billing&PrimaryName()14)ValueCode838of((. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CMS-for13)Person:Number(MedicareCreditBalanceReasonFORMPageContactPhoneBalanceTHE PEOPLE OF THE STATE OF NEW YORK TOOutstandingINSTRUCTIONS,of12)(MedicareAmountCredit11)MethodofPaymentPROVIDER(ofGREETINGS:-ReportBalance10)MedicareRepaidAmountREPORT(CreditWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,BALANCEBalanceoflocated at County ofMedicareBalancePage9)(CreditAmounto'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 roomCREDITClosed)DetailCredit8)ReportMEDICARE(CostOpen/(YY)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.DateDD/7)IN(PaidMM/ARE(YY)PAGE6)DD/(DischargeDateMM/, one of the Justices of theTHISMedicare(YY)Court in Witness, Honorableday of, 20 County,AdmissionCOMPLETING5)DD/(DateMM/(of4)Bill((Attorney must sign above and type name below)TypeFORINSTRUCTIONS)B3)Number(ICNorAttorney(s) forANumberServicesIndicateServices2)(HICOffice and P.O. AddressHuman(Medicaidand&NameTelephone No.: Facsimile No.: E-Mail Address:Part:Health03)Name:Number:10/1)((Ending:ofMedicare838BeneficiaryProviderProviderQuarterMedicareDepartmentforCMS-Mobile Tel. No.:CentersFormAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OFDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Medicare Credit Balance Report Provider InstructionsCalendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)GeneralThe Paperwork Burden Reduction Act of 1995 was enacted to inform you about why the Government collects information and how it uses the information. In accordance with sections 1815(a) and 1833(e) of the Social Security Act (the Act), the Secretary is authorized to request information from participating providers that is necessary to properly administer the Medicare program. In addition, section 1866(a)(1)(C) of the Act requires participating providers to furnish information about payments made to them, and to refund any monies incorrectly paid. In accordance with these provisions, all providers participating in the Medicare program are to complete a Medicare Credit Balance Report (CMS-838) to help ensure that monies owed to Medicare are repaid in a timely manner.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The CMS-838 is specifically used to monitor identification and recovery of credit balances owed to Medicare. A credit balance is an improper or excess payment made to a provider as the result of patient billing or claims processing errors. Examples of Medicare credit balances include instances where a provider is:THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS: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 Co
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