s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DEPARTMENT OF HEALTH AND HUMAN SERVICESForm ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICESOMB No. 0938-0267COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEYTHE PEOPLE OF THE STATE OF NEW YORK TO(3) Either(f) A prosthetist must§485.70 Personnel qualifications. This section sets forth the qualifications that must be met, as a condition of participation, under §485.58, and as a condition of coverage of services under §410.100 of this chapter.(i) Be eligible to take the registry(1) Be licensed by the State in which practicing,if applicable; (2) Have successfully completed a trainingprogram in prosthetics that is jointly recognized by the American Council on Education and the American Board for Certification in Orthotics and Prosthetics; andGREETINGS:examination for respiratory therapists administered by the National Board for Respiratory Therapy, Inc.; or (ii) Have equivalent training and(a) A facility physician must be a doctor of medicineor osteopathy who (1) Is licensed under State law to practiceWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,experience as determined by the National Board for Respiratory Therapy, Inc.(3) Be eligible to take the Board's certificationlocated at County of(k) A respiratory therapy technician must, 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 ofmedicine or surgery; and (2) Has had, subsequent to completing a 1-year(1) Be licensed by the State in which practicing,examination in prosthetics. (g) A psychologist must be certified or licensed bythe State in which he or she is practicing, if that State requires certification or licensing, and must hold a master's degree in psychology from an educational institution approved by the State in which the institution is located.if applicable; (2) Have successfully completed a traininghospital internship, at least 1 year of training in the medical management of patients requiring rehabilitation services; or (3) Has had at least 1 year of full-time orYour 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.program accredited by the Committees on Allied Health Education and Accreditation (CAHEA) in collaboration with the Joint Review Committee of Respiratory Therapy Education; and(h) A registered nurse must be a graduate of anpart-time experience in a rehabilitation setting providing physicians' services similar to those required in this subpart. (b) A licensed practical nurse must be licensed as a(3) Either, one of the Justices of theCourt in Witness, Honorable, 20 County,day of(i) Be eligible to take the certificationapproved school of nursing and be licensed as a registered nurse by the State in which practicing, if applicable. (i) A rehabilitation counselor mustpractical or vocational nurse by the State in which practicing, if applicable. (c) An occupational therapist and an occupational(1) Be licensed by the State in which practicing,(Attorney must sign above and type name below)examination for respiratory therapy technicians administered by the National Board for Respiratory Therapy, Inc.; or (ii) Have equivalent training and experience asif applicable; (2) Hold at least a bachelor's degree; and (3) Be eligible to take the certificationtherapist assistant must meet the qualifications set forth in §484.4 of this chapter. (d) An orthotist mustdetermined by the National Board for Respiratory Therapy, Inc.(1) Be licensed by the State in which practicing,Attorney(s) for(l) A social worker mustif applicable; (2) Have successfully completed a training(1) Be licensed by the State in which practicing,examination administered by the Commission on Rehabilitation Counselor Certification. (j) A respiratory therapist mustprogram in orthotics that is jointly recognized by the American Council on Education and the American Board for Certification in Orthotics and Prosthetics; and(1) Be licensed by the State in which practicing,if applicable; (2) Hold at least a bachelor's degree from aOffice and P.O. Addressif applicable; (2) Have successfully completed a training(3) Be eligible to take that Board's certificationprogram accredited by the Committee on Allied Health Education and Accreditation (CAHEA) in collaboration with the Joint Review Committee for Respiratory Therapy Education; andschool accredited or approved by the Council on Social Work Education; and (3) Have 1 year of social work experience in aTelephone No.: Facsimile No.: E-Mail Address:examination in orthotics. (e) A physical therapist and a physical therapisthealth care setting. (m) A speech-language pathologist must meet theassistant must meet the qualifications set forth in §485.705.qualifications set forth in §485.705(b)(2) of this chapter.Mobile Tel. No.:Page 1Form CMS-360 (09/03)American LegalNet, Inc. www.USCourtForms.coms): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DEPARTMENT OF HEALTH AND HUMAN SERVICESForm ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICESOMB No. 0938-0267COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEYTHE PEOPLE OF THE STATE OF NEW YORK TOPROVIDER NUMBERFACILITY NAME AND ADDRESS (City, State, Zip Code)VENDOR NUMBERGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableSURVEY DATEType of Survey 1. Initial Survey,Resurvey2.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 ofYour 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., one of the Justices of theCourt in Witness, Honorable, 20 County,day of(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:PageForm CMS
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