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New York State Department of Health
Office of Health Insurance Programs
Division of Finance & Rate Setting
Bureau of Hospital & Clinic Rate Setting

Ambulatory Health Care Facility (AHCF) Cost Reporting Election

In accordance with Public Health Law Section 2807 (7-b)(b), the below named facility is electing to maintain all books and records utilized for cost reporting and Medicaid reimbursement purposes based on the selection below. It is understood that, based on Public Health law, this determination is a one- time decision and is not revocable.

Option Selected (please check one):

      _______ The AHCF cost report will be completed on a calendar year basis.

      _______ The AHCF cost report will be completed on a July 1st through June 30th fiscal year period.

Facility Name ____________________________________________________________________

Operating Certificate Number:_______________________________________________________

Authorized Signer:

           Print Name ________________________________________________________________

           Signature __________________________________________________________________
                             The individual signed above has the authority to sign this agreement.

           Title _______________________________________________________________________

           Date: __________________________________

Public Health Law Section 2807(7-b)(b)states:

        (b) Notwithstanding any contrary provision of law, all diagnostic and treatment centers certified on or before September second, nineteen hundred ninety-seven shall, not later than September second, nineteen hundred ninety-seven, notify the commissioner whether they intend to maintain all books and records utilized by the diagnostic and treatment center for cost reporting and reimbursement purposes on a calendar year basis or, commencing on July first, nineteen hundred ninety-six, on a July first through June thirtieth basis, and shall thereafter maintain all books and records on such basis. All diagnostic and treatment centers certified after September second, nineteen hundred ninety-seven shall notify the commissioner at the time of certification whether they intend to maintain all books and records on a calendar year basis or on or a July first through June thirtieth basis, and shall thereafter maintain all books and records on such a basis.