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Model Form D - (2013) PDF, 56KB

Model Form D - (2013) PDF, 56KB-2025

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The document is a request form from the Department of Health & Human Services for transferring an issue from an individual appeal to a group appeal within the Provider Reimbursement Review Board (PRRB). It outlines the necessary information and certifications required for the transfer, including details about the provider, the issue being transferred, and compliance with regulations. The form emphasizes that transfers can only be made to existing or previously requested group appeals and includes sections for certification by both the provider and group representative.

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Click ‘Get Form’ to open the Model Form D - (2013) PDF in the editor.
Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your submission.
Fill in the 'Prior PRRB Case No(s).' if applicable, ensuring you provide a complete transfer history if necessary.
In the 'Provider Name' and 'Provider Number' fields, input your organization's details accurately.
Complete the 'Fiscal Year Ended' section with the relevant date to clarify your reporting period.
Describe the issue being transferred in detail, including any relevant audit adjustment numbers.
Indicate whether this is the last issue remaining in your individual appeal by checking 'YES' or 'NO'.
Provide information about the group case number and name where you are transferring the issue. If not assigned yet, include additional requested details.
Complete sections regarding commonly owned providers and CIRP group appeals as applicable, ensuring all required contact information is filled out.
Review all entries for accuracy before signing and dating at the certification section to finalize your request.

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