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20 CFR 404.1503b(c) - Fact Sheet
ICR 202607-0960-007 · OMB 0960-0803 · Object 170780400.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | 20 CFR 404.1503b(c) - Fact Sheet |
| Author | ALC |
| Last Modified By | Microsoft® Word 2010 |
| File Modified | 2016-09-20 |
| File Created | 2016-08-15 |
| Conversion State | complete |
Extracted Text
WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT – DO NOT REMOVE I, [Name and Title], was excluded from participating in any Federal health care program under section 1128 of the Social Security Act by the Office of Inspector General of the Department of Health and Human Services because [Reason why you were excluded]. My section 1128 exclusion became effective on [Date(s)]. I anticipate that my section 1128 exclusion will last until [Date(s)]. HHS’ OIG [has/has not] waived my section 1128 exclusion.