Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 4/3/2007
Consent For Home Visit {CMS-36}
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Description
<document>theHonorableCountyofinroom.oradjourneddate,totestifyandgiveevidenceasawitnessinthisactiononthepartofthethepartyonwhosebehalfthissubpoenawasissuedforamaximumpenaltyof$50andalldamagessustainedasaresultofyourfailuretocomply.THEPEOPLEOFTHESTATEOFNEWYORKTOCourtin.......Yourfailuretocomplywiththissubpoenaispunishableasacontemptofcourtandwillmakeyouliableto.Witness,HonorableDEPARTMENTOFHEALTHANDHUMANSERVICESFormCMS-36U3(12-90)CENTERSFORMEDICARE&MEDICAIDSERVICEShomehealthservicesthatIreceivefromthe.ensurethattheFederalrequirementsaremetandtoassistinevaluatingtheeffectivenessandqualityofwaivedbymyconsent.IhavebeentoldandIunderstandthatrefusaltoconsenttoahomehealthvisitwillBENEFICIARYNAME:Bythisdocument,IherebyconsenttohaveState/FederalhealthsurveypersonnelconductahomevisittoIhavenoeffectonthelevelornatureofMedicare/MedicaidbenefitstowhichIamentitled..understandthatconsentforthisvisitisvoluntaryandnoneofmyrightstoconfidentialityorprivacyareBENEFICIARY,ORREPRESENTATIVEOFTHEBENEFICIARY,SIGNATURE:.....,.onthe..County,.....GREETINGS: WECOMMANDYOU,thatallbusinessandexcusesbeinglaidaside,youandeachofyouattendbefore....dayof.locatedat..dayof............,atthe.20..,.s)CONSENTFORHOMEVISIT20..,.at..ADDRESS:.(Attorneymustsignaboveandtypenamebelow)Attorney(s)forOfficeandP.O.AddressTelephoneNo.: FacsimileNo.:E-MailAddress:.. Mobile:Courto'clockintheTel.No.:,oneoftheJusticesofthe(NameofHomeHealthAgency)noon,andatanyrecessedAmericanLegalNet,Inc.www.USCourtForms.comDATE:,</document>
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