Official Federal Forms > Centers For Medicare And Medicaid Services

Monthly Intermediary Report On Medicare Secondary Payer Savings CMS-1563 - Official Federal Forms

Monthly Intermediary Report On Medicare Secondary Payer Savings Form. This is a national form and can be used in Centers For Medicare And Medicaid Services .
 Fillable pdf Last Modified 2/17/2004
Get this form for FREE as a print-only pdf

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),
Link/Embed this Document
URL
Embed


Popular Searches

  1. certificate of service
  2. JUDGMENT
  3. default judgment
  4. child support
  5. answer
  6. answer to complaint
  7. petition
  8. order to show cause
  9. writ
  10. affidavit

Bookmark and Share