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Health Financial Systems LUTHERAN HOSPITAL OF INDIANA In Lieu of Form CMS255210 This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim FORM APPROVED payments

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Time 3:42 pm is a specific point in the afternoon.

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Individuals or entities who are instructed to report or document activities at 3:42 pm.

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Ensure the accurate reporting of events or information that occurred at 3:42 pm.

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To document activities or events that took place at 3:42 pm.

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Details of the specific activities or events that occurred at 3:42 pm.

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