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Petition to the State Health Coordinating CouncilRegarding a Special Need Petition for a Linear Accelerator in Service Area 242022 State Medical Facilities Plan July28,2021 Petitioner:Contact:Name:CarteretHealthCareName:HarveyCaseAddress:3500ArendellStreet, MoreheadCity,NC28557Email:hcase@carterethealth.phone:(252)4996000STATEMENT OF REQUESTED ADJUSTMENT CarteretHealthCare(CHC)requestsanadjustedneeddeterminationin
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Gather all necessary supporting documents such as invoices, receipts, and other relevant paperwork.
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Clearly state the reason for the requested adjustment and provide any additional information or evidence to support your claim.
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Who needs statement of requested adjustment?

01
Individuals who have experienced a discrepancy in billing, pricing, or services rendered and wish to request an adjustment.
02
Businesses that require adjustments to financial statements or invoices due to errors or discrepancies.
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The statement of requested adjustment is a form used to request changes or adjustments to previously submitted information.
Individuals or entities who need to make adjustments to previously filed information are required to file a statement of requested adjustment.
The statement of requested adjustment can be filled out by providing the necessary information and details required for the adjustment request.
The purpose of the statement of requested adjustment is to request changes or corrections to previously submitted information.
The statement of requested adjustment must include the details of the original submission, the requested changes, and any supporting documentation.
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