Form Cms-462l - Adverse Acti0n Extract For Snfs And Nfs Page 2
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6ADVERSE ACTION EXTRACT FOR SNFs AND NF
s
PART 2
(M M D D Y Y)
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27. DATE REQUEST FOR ADMINISTRATIVE APPEAL RECEIVED BY CMS: .............................
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28. ADMINISTRATIVE LAW JUDGE (ALJ) DECISION: DATE RENDERED: ................................
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29. *CMS DETERMINATION: ........................................
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30. DEPARTMENTAL APPEALS BOARD (DAB) DECISION: DATE RENDERED: ......................
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31. *CMS DETERMINATION: ........................................
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32. DATE APPEAL FILED IN THE U. S. DISTRICT COURT: .........................................................
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33. U. S. DISTRICT COURT DECISION: DATE RENDERED: .......................................................
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34. *CMS DETERMINATION: ........................................
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35. DATE APPEAL FILED IN THE U. S. CIRCUIT COURT OF APPEALS: ....................................
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36. U. S. CIRCUIT COURT OF APPEALS DECISION: DATE RENDERED: .................................
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37. *CMS DETERMINATION: ........................................
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38. DATE REQUEST FOR ADMINISTRATIVE APPEAL RECEIVED BY STATE: ..........................
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39. ADMINISTRATIVE DECISION: DATE RENDERED: ................................................................
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40. *STATE DETERMINATION: .....................................
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41. DATE APPEAL FILED IN THE STATE DISTRICT COURT: ......................................................
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42. STATE DISTRICT COURT DECISION: DATE RENDERED: ...................................................
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43. *STATE DETERMINATION: .....................................
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44. DATE APPEAL FILED IN THE STATE COURT OF APPEALS: ................................................
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45. STATE COURT OF APPEALS DECISION: DATE RENDERED: .............................................
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46. *STATE DETERMINATION: .....................................
DATE(S) APPEAL FILED ON BEHALF OF THE FACILITY IN STATE SUPERIOR COURT(S):
(M M D D Y Y)
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47. COURT: ________________________________________________________________ 48.
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________________________________________________________________
STATE SUPERIOR COURT(S) DECISION(S) RENDERED:
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49. COURT: ________________________________________________________________ 50.
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________________________________________________________________
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51. *STATE DETERMINATION: .....................................
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* (CMS / STATE DETERMINATION CODES ARE (R = REVERSED, S = SUSTAINED, M = MODIFIED))
FORM CMS-462L (7/95)
PAGE 2 of 2
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