Appendix A to Subpart C of Part 1001
42:5.0.2.5.2.3.69.21.1 : Appendix A
Appendix A to Subpart C of Part 1001
The following is a sample written disclosure for purposes of
satisfying the requirements of §
1001.952(v)(3)(i)(B)(1)(i) of this part. This form is
for illustrative purposes only; parties may, but are not required
to, adapt this sample written disclosure form.
Notice of Ambulance Restocking Program
Hospital X offers the following ambulance restocking
program:
1. We will restock all ambulance providers (other than ambulance
providers that do not provide emergency services) that bring
patients to Hospital X [or to a subpart of Hospital X, such as the
emergency room] in the following category or categories: [insert
description of category of ambulances to be restocked, i.e., all
ambulance providers, all ambulance providers that do not charge
patients or insurers for their services, or all nonprofit and
Government ambulance providers]. [Optional: We only offer
restocking of emergency transports.]
2. The restocking will include the following drugs and medical
supplies, and linens, used for patient prior to delivery of the
patient to Hospital X: [insert description of drugs and medical
supplies, and linens to be restocked].
3. The ambulance providers [will/will not] be required to pay
for the restocked drugs and medical supplies, and linens.
4. The restocked drugs and medical supplies, and linens, must be
documented as follows: [insert description consistent with the
documentation requirements described in § 1001.952(v). By way of
example only, documentation may be by a patient care report filed
with the receiving facility within 24 hours of delivery of the
patient that records the name of the patient, the date of the
transport, and the relevant drugs and medical supplies.]
5. This restocking program does not apply to the restocking of
ambulances that only provide non-emergency services or to the
general stocking of an ambulance provider's inventory.
6. To ensure that Hospital X does not bill any Federal health
care program for restocked drugs or supplies for which a
participating ambulance provider bills or is eligible to bill, all
participating ambulance providers must notify Hospital X if they
intend to submit claims for restocked drugs or supplies to any
Federal health care program. Participating ambulance providers must
agree to work with Hospital X to ensure that only one party bills
for a particular restocked drug or supply.
7. All participants in this ambulance restocking arrangement
that bill Federal health care programs for restocked drugs or
supplies must comply with all applicable Federal program billing
and claims filing rules and regulations.
8. For further information about our restocking program or to
obtain a copy of this notice, please contact [name] at [telephone
number].
Dated:____ /s/____ Appropriate officer or official [66 FR 62991,
Dec. 4, 2001]