Fillable 1128%28b%29%285%29exclusionperiodcoterminouswithsuspensionorexclusionterm

Fill Online, Printable, Fillable, Blank 1128%28b%29%285%29exclusionperiodcoterminouswithsuspensionorexclusionterm Form

Use Fill to complete blank online HEALTH AND HUMAN SERVICES (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

1128%28b%29%285%29exclusionperiodcoterminouswithsuspensionorexclusionterm

On average this form takes 4 minutes to complete

The 1128%28b%29%285%29exclusionperiodcoterminouswithsuspensionorexclusionterm form is 3 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 11 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Health and Human Services

BROWSE HEALTH AND HUMAN SERVICES (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
United States Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
In the Case of:
Date:
Petitioner,
- v. -
The Inspector General.
INFORMAL BRIEF OF PETITIONER
The Inspector General (I.G.) argues that he is authorized to exclude you from
participating in Medicare, Medicaid, and other federally-funded health care
programs because you were suspended, excluded or otherwise sanctioned under a
federal or State health care program as is described at section 1128(b)(5) of the
Social Security Act. The length of the exclusion is for a period of time that is not
less than the period during which you are suspended, excluded, or otherwise
sanctioned.
I. Were you suspended, excluded, or otherwise sanctioned under a federal or
State health care program under the circumstances that are described at
section 1128(b)(5)?
A. Do you agree that you were suspended, excluded or otherwise
sanctioned by a federal or a State health care program?
)
)
)
)
)
)
)
)
)
)
Docket No. C-
-
No
Yes
XXX
XX
If you disagree, explain why you disagree. State which exhibits support
your argument and explain why they do.
B. Do you agree that you were suspended, excluded, or otherwise
sanctioned for reasons bearing on your professional competence,
professional performance, or financial integrity?
If you disagree, explain why you disagree. State which exhibits support
your argument and explain why they do.
II. Do you believe that an in-person hearing is necessary to decide your case?
Do you have any testimony that you wish to offer at an in-person hearing?
If you have testimony that you wish to offer, provide the following:
1. The name of each witness whose testimony you want to offer.
2. A description of each witness’ proposed testimony and an explanation of
why you believe that the testimony relates to any of the arguments you
want to offer in connection with item I.
No
Yes
No
Yes
No
Yes
3. An explanation of why the proposed testimony does not duplicate
something that is already stated in an exhibit.
III. Do you have any other arguments you wish to make? If so, please state
them here. State which exhibits support your argument(s) and explain why they
do.
Petitioner or Petitioner’s Representative
Date:
Print Form
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

1128%28b%29%285%29exclusionperiodcoterminouswithsuspensionorexclusionterm

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document