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UM 1726, OTHER FILING/PLEADING, 9/11/2015 · Form 481 (High-cost per 47 CFR § 54.313, Low-income per 54.422)1 Form 690 (Mobility Fund per 47 CFR § 54.1009) Affidavit for High-Cost

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Page 1: UM 1726, OTHER FILING/PLEADING, 9/11/2015 · Form 481 (High-cost per 47 CFR § 54.313, Low-income per 54.422)1 Form 690 (Mobility Fund per 47 CFR § 54.1009) Affidavit for High-Cost

Page 2: UM 1726, OTHER FILING/PLEADING, 9/11/2015 · Form 481 (High-cost per 47 CFR § 54.313, Low-income per 54.422)1 Form 690 (Mobility Fund per 47 CFR § 54.1009) Affidavit for High-Cost

Page 3: UM 1726, OTHER FILING/PLEADING, 9/11/2015 · Form 481 (High-cost per 47 CFR § 54.313, Low-income per 54.422)1 Form 690 (Mobility Fund per 47 CFR § 54.1009) Affidavit for High-Cost

Page 4: UM 1726, OTHER FILING/PLEADING, 9/11/2015 · Form 481 (High-cost per 47 CFR § 54.313, Low-income per 54.422)1 Form 690 (Mobility Fund per 47 CFR § 54.1009) Affidavit for High-Cost

Page 5: UM 1726, OTHER FILING/PLEADING, 9/11/2015 · Form 481 (High-cost per 47 CFR § 54.313, Low-income per 54.422)1 Form 690 (Mobility Fund per 47 CFR § 54.1009) Affidavit for High-Cost

Page 6: UM 1726, OTHER FILING/PLEADING, 9/11/2015 · Form 481 (High-cost per 47 CFR § 54.313, Low-income per 54.422)1 Form 690 (Mobility Fund per 47 CFR § 54.1009) Affidavit for High-Cost

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PROVIDER CCN: 14-0110 OTTAWA REGIONAL HOSPITAL & …cfr §412.348(g)? if yes, complete worksheet l, part iii and l-1, parts i through iii. 47 is this a new hospital under 42 cfr §412.300

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