Consent For Home Visit {CMS-36} | Pdf Fpdf Doc Docx | Official Federal Forms

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Consent For Home Visit {CMS-36} | Pdf Fpdf Doc Docx | Official Federal Forms

Consent For Home Visit {CMS-36}

This is a Official Federal Forms form that can be used for Centers For Medicare And Medicaid Services.

Alternate TextLast updated: 4/3/2007

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<document>theHonorableCountyofinroom.oradjourneddate,totestifyandgiveevidenceasawitnessinthisactiononthepartofthethepartyonwhosebehalfthissubpoenawasissuedforamaximumpenaltyof$50andalldamagessustainedasaresultofyourfailuretocomply.THEPEOPLEOFTHESTATEOFNEWYORKTOCourtin.......Yourfailuretocomplywiththissubpoenaispunishableasacontemptofcourtandwillmakeyouliableto.Witness,HonorableDEPARTMENTOFHEALTHANDHUMANSERVICESFormCMS-36U3(12-90)CENTERSFORMEDICARE&amp;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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