Model Form G: Schedule Of Providers In Group - Cms Form

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Model Form G: Schedule of Providers in Group
Case No.: _________________
Page _______ of _______
Group Name: _______________________________________________________________________
Date Prepared: _________________
Group Representative: ________________________________________________________________
Lead Intermediary: __________________________________________________
Issue: ____________________________________________________________________________________________________________________________
A
B
C
D
E
F
G
Date of
Date of
Hearing
Direct Add /
Request /
Provider
Provider Name / Location
Intermediary /
Date of Final
Add Issue
No. of
Audit
Amount in
Prior Case
Transfer(s)
#
Number
(city, county, state)
FYE
MAC
Determination
Request
Days
Adj. No.
Controversy
No(s).
to Group
Total Amount in Controversy for all Providers: $______________

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