Agreement - Indiana Family & Social Services Administration - Medicaid Managed Care Ambulance Services for SBFD

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South Bend Fire Department/EMS May 23, 2017 Page 2 of 2 The cover letter must include your facility's name and address and your federal tax identification number. You will receive your Indiana Medicaid Governmental Ambulance Payment Adjustment for managed care services for calendar year 2014 after this information has been received. APPEAL SECTION This notification constitutes an appealable order. If you disagree with this determination, you have the right to appeal under 405 IAC 1-1.5. In order to assert your appeal rights, you must file an appeal request within fifteen (15) days of your receipt of this letter. The appeal request must state that you are the party to whom the order is specifically directed; that you are adversely affected by the determination; and that you are entitled to review under the law. Please refer to the rule for further information on your appeal rights. Appeals should be sent to the following address: Jennifer Walthall, M.D, MPH, Secretary MS07-Office of Medicaid Policy and Planning ATTN: Mr. Chris Fletcher 402 West Washington Room W382 Indianapolis, IN 46204 A copy of this notice must accompany your appeal request. A copy of the appeal should also be sent to Myers and Stauffer LC at the address listed below. Failure to file an appeal request within fifteen (15) days from receipt of this letter will result in the waiver of any right to appeal this determination. if you elect to appeal this determination, you must; also file a statement of issues within forty-five (45) days after you receive notice of this determination. The statement of issues should be sent to the same address as the appeal request. The statement of issues should conform to 405 IAC 1-1.5-2 (e). The statement of issues and the appeal request may be filed together. Please also forward a copy of the statement of issues to Myers and Stauffer LC at the following address: Myers and Stauffer LC Attn: Berry Bingaman 9265 Counselors Row, Suite 100 Indianapolis, IN 46240 If you elect to waive your right to an appeal, please fax or mail such notification to Berry Bingaman, in care of Myers and Stauffer LC. The fax telephone number is (317) 571-8481. Sincerely, Berry Bingaman, CPA Myers and Stauffer LC cc: Jennifer White, OMPP Enclosure