Exhibit I: Medicare Credit Balance Report Certification Page

20.8 - Exhibit I: Medicare Credit Balance Report Certification Page (Rev. 99, Issued: 06-30-06; Effective/Implementation Dates: 10-02-06) DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0600 MEDICARE CREDIT BALANCE REPORT CERTIFICATION PAGE The Medicare Credit Balance Report is required under the authority of Sections 1815(a), 1833(e), 1886(a)(1)(C) and related provisions of the Social Security Act. Failure to submit this report may result in a suspension of payments under the Medicare program and may affect your eligibility to participate in the Medicare program. ANYONE WHO MISREPRESENTS, FALSIFIES, CONCEALS OR OMITS ANY ESSENTIAL INFORMATION MAY BE SUBJECT TO FINE, IMPRISONMENT OR CIVIL MONEY PENALTIES UNDER APPLICABLE FEDERAL LAWS. CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER I HEREBY CERTIFY that I have read the above statements and that I have examined the accompanying credit balance report prepared by Provider Name Provider 6-Digit Number for the calendar quarter ended and that it is a true, correct, and complete statement prepared from the books and records of the provider in accordance with applicable Federal laws, regulations and instructions. (Sign) Officer or Administrator of Provider (Print) Name and Title (Print) Date CHECK ONE: Qualify as a Low Utilization Provider. The Credit Balance Report Detail Page(s) is attached. There are no Medicare credit balances to report for this quarter. (No Detail Page(s) attached.) Contact Person Telephone Number Form CMS-838 (10/03) INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT – PROVIDER INSTRUCTIONS, FORM CMS-838