20 CFR 404.1503b(c) & 416.903b(c)

WRITTEN STATEMENT
REGARDING SECTION 223(d)(5)(C)
OF THE SOCIAL SECURITY ACT –
DO NOT REMOVE

I, [Name and Title], was excluded from participating in any Federal health care program
under section 1128 of the Social Security Act by the Office of Inspector General of the
Department of Health and Human Services because [Reason why you were excluded]. My
section 1128 exclusion became effective on [Date(s)]. I anticipate that my section 1128
exclusion will last until [Date(s)].
HHS’ OIG [has/has not] waived my section 1128 exclusion.