Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 4/3/2007
Monthly Intermediary Report On Medicare Secondary Payer Savings {CMS-1563}
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Description
<document>INTERMEDIARYNAMEFormCMS-1563(11-97)Unpaid(CostAvoided) MSPClaims 1.Number 2.DollarValue FullRecoveries 3.Number PartialRecoveries 5.Number4.DollarValue 6.DollarValue SpecialProjects 7.Number 8.DollarValue Totals 9.Number (Lines1+3+5+7) 10.DollarValue (Lines2+4+6+8) REMARKS SIGNATUREDEPARTMENTOFHEALTHANDHUMANSERVICESCENTERSFORMEDICARE&MEDICAIDSERVICESTOTAL (i)ItheHonorableCountyofinroom.oradjourneddate,totestifyandgiveevidenceasawitnessinthisactiononthepartofthethepartyonwhosebehalfthissubpoenawasissuedforamaximumpenaltyof$50andalldamagessustainedasaresultofyourfailuretocomply.TOTHEPEOPLEOFTHESTATEOFNEWYORKCourtin...MEDICARESECONDARYPAYERSAVINGS..MONTHLYINTERMEDIARYREPORTON..Yourfailuretocomplywiththissubpoenaispunishableasacontemptofcourtandwillmakeyouliableto.Witness,Honorable...WORKER'SCOMP BLACKLUNG&VA (ii) WORKINGAGED (iii)..NUMBER.TITLE,.onthe..County,.....GREETINGS: WECOMMANDYOU,thatallbusinessandexcusesbeinglaidaside,youandeachofyouattendbefore....dayof.locatedat..dayof....ESRD (iv)...STATE.....,atthe.20..,.20..,.atAUTO/NFLT (v)...(Attorneymustsignaboveandtypenamebelow)OfficeandP.O.AddressE-MailAddress:.. MobileDefendant(s) :DATEAttorney(s)forTelephoneNo.:FacsimileNo.:REPORTINGPERIOD(MO.&YR.)Courto'clockintheTel.No.:,oneoftheJusticesoftheDISABLED (vi)noon,andatanyrecessedAmericanLegalNet,Inc.www.USCourtForms.comLIABILITY (vii),</document>
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