Health Insurance Benefits Agreement With Organ Procurement Organization Pusuant To 1138(b) {CMS-576A}

<document>s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Form ApprovedDEPARTMENT OF HEALTH AND HUMAN SERVICESOMB No. 0938-0512CENTERS FOR MEDICARE &amp; MEDICAID SERVICESHEALTH INSURANCE BENEFITS AGREEMENTTHE PEOPLE OF THE STATE OF NEW YORK TOAGREEMENT WITH ORGAN PROCUREMENT ORGANIZATION PURSUANT TO§1138(b) OF THE SOCIAL SECURITY ACT (the Act)For the purpose of establishing eligibility under titles XVIII and XIX of the Act hereinafter referred to as the Organ Procurement Organization, hereby agrees;(Insert Name of Facility)(A) To maintain compliance with the requirements of titles XVIII and XIX of the Act, §1138 of the Act, applicable regulations including the conditions set forth inGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorablePart 486, subpart G, title 42 of the Code of Federal Regulations, those conditions of the Organ Procurement and Transplantation Network established under §372 of the Public Health Service Act and to report promptly to the Centers for Medicare &amp; Medicaid Services (CMS) any failure to do so; (B) To file a cost report in accordance with 42 CFR 413.24(f) within 3 months after the end of each fiscal year; (C) To permit CMS to designate an intermediary to determine the interim reimbursement rate payable to the transplant hospitals for services provided by the,located at County of, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofOPO and to make a determination of reasonable cost based upon the cost report filed by the OPOs; (D) To provide such budget or cost projection information as may be required to establish an initial interim reimbursement rate; (E) To pay to CMS amounts that have been paid by CMS to transplant hospitals and that are determined to be in excess of the reasonable cost of the servicesprovided by the OPO; (F) Not to charge any individual for items or services for which that individual is entitled to have payment made under §1881 of the Act; (G) To maintain and make available to the Secretary, the Comptroller General, or their designee data that show the number of organs procured and trans-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.planted; and (H) To maintain data in a format that can be readily assumed by a successor OPO and to turn over to the Secretary copies of all records and data necessary toassure uninterrupted service by a successor OPO that is newly designated by CMS., one of the Justices of theThis agreement, upon submission by the Organ Procurement Organization and upon acceptance for filing by the Secretary of Health and Human Services, shall be binding on the Organ Procurement Organization and the Secretary. The agreement may be terminated by either party in accordance with regulatory requirements. In the event of termination, costs for the procurement of organs will not be available to the Organ Procurement Organization furnished on or after the effective date of the termination.Court in Witness, Honorable, 20 County,day of(Attorney must sign above and type name below)This agreement shall become effective on the date specified below by the Secretary or his Delegate, and shall remain in effect unless terminated. FOR THE ORGAN PROCUREMENT ORGANIZATIONACCEPTED FOR SECRETARY OF HEALTH AND HUMAN SERVICES BY:NAMENAMEAttorney(s) forTITLETITLEDATEDATEOffice and P.O. AddressEFFECTIVE DATE OF AGREEMENTTelephone No.: Facsimile No.: E-Mail Address:According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0512. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.Mobile Tel. No.:Page 1Form CMS-576A (01/93)American LegalNet, Inc. www.USCourtForms.com</document>