Hs 328 2025

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The document outlines the regulations governing the effective date of provider agreements for services under Medicare and Medicaid in California. It specifies that the effective date is determined by the completion of an onsite survey, contingent upon meeting federal health and safety standards. If a provider fails to meet these requirements, the agreement becomes effective when compliance is achieved or when an acceptable correction plan is submitted. The notice also includes instructions for returning a signed acknowledgment to the California Department of Public Health.

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Click ‘Get Form’ to open it in the editor.
Begin by reviewing the notice regarding the effective date of reimbursement. This section outlines important regulations that govern provider agreements.
In the signature field, provide your signature to confirm that you have received and understood the notice. This is crucial for compliance.
Next, print your name clearly in the designated area below your signature. Ensure that it matches any official documentation.
Finally, enter the date on which you are signing this form. This helps establish a clear timeline for your agreement.

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Hs 328 2025

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