TAILIEUCHUNG - MEDICARE CREDIT BALANCE REPORT CERTIFICATION PAGE

The properties of nonsophisticated borrowers’ competitive-equilibrium contracts, and the restriction disallowing disproportionately large penalties for deferring small amounts of repayment, have close parallels in real-life credit markets and their regulation. As has been noted by researchers, the baseline repayment terms in credit-card and subprime mortgage contracts are typically quite strict, and there are large penalties for deviating from these terms. For example, most subprime mortgages postulate drastically increased monthly payments shortly after the origination of the loan or a large “balloon” payment at the end of a short loan period, and failing to make these payments and refinancing triggers significant prepayment penalties | DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved 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 endedand 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 INSTRUCTIONS FOR COMPLETING THIS PAGE ARE IN MEDICARE CREDIT BALANCE REPORT -PROVIDER INSTRUCTIONS FORM CMS-838 Form CMS-838 10 03 Form Approved OMB No. 0938-0600 Department of Health and Human Services Centers for Medicare Medicaid Services Medicare Credit Balance Report Detail Page Provider Name Page of Provider Number Contact Person Quarter Ending Phone Number - Medicare Part Indicate A

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