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HOSPITAL/HEALTH SYSTEM ATTESTATION OF COMPLIANCE WITH FACILITY FEE PATIENT NOTIFICATION AND TRANSPARENCY REQUIREMENTS OF C.G.S. SEC. 19a508c, AFFIDAVIT CALENDAR YEAR 2019 Indicate, through the use
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01
Download the facilityfeenotice-affidavit2019.pdf from the ct.gov website.
02
Read the instructions carefully before filling out the form.
03
Provide your personal information, including your name, address, and contact details.
04
State the facility's name and address for which the notice is being submitted.
05
Indicate the specific fees being contested, including details on billed amounts.
06
Sign the affidavit where indicated, certifying that the information provided is true and accurate.
07
Submit the filled form to the appropriate state agency or designated recipient by the deadline specified.

Who needs facilityfeenotice-affidavit2019pdf - ctgov?

01
Individuals or entities contesting facility fees charged by a state institution.
02
Anyone required to provide an affidavit regarding fees as part of a legal or administrative process.
03
Residents who have been billed for services from state facilities and wish to dispute the charges.
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The facility fee notice affidavit 2019 PDF from CT.gov is a document that certifies compliance with facility fee notice requirements as mandated by Connecticut regulations.
Any healthcare facility that charges facility fees and is licensed in Connecticut is required to file the facility fee notice affidavit.
To fill out the affidavit, complete the required fields with accurate facility information, detail the service provided, and ensure all necessary signatures are obtained before submission.
The purpose of the affidavit is to ensure transparency regarding facility fees charged to patients and to comply with state regulations.
The affidavit must include the facility's name, address, the services provided, the facility fee structure, and contact information for inquiries.
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