37 Pa. Code § 197.85 - Form of notice of appeal

The following is the form of notice of appeal:

COMMONWEALTH OF PENNSYLVANIA

STATE HEALTH FACILITY HEARING BOARD

IN RE:	:
:	DOCKET NO. L-
:

NOTICE OF APPEAL-LICENSURE

1. Appellant is______________________________________________.

(name, address and telephone number)

2. Appellant appeals the following decision of the Department of Health:

______________________________________________.

(identify the decision, e.g. denial of application for license to operate and maintain a skilled nursing facility, etc.)

3. The docket number or identifying number in the proceedings before the Department of Health, if any is:______________________________________________.

4. The date of mailing of the decision of the Department of Health is______________.

5. Appellant lists the following specifications of objections to the decision of the Department as the basis for its appeal:

______________________________________________

(e.g., decision not supported by substantial evidence, etc.)______________________________________________ ______________________________________________.

__________________________

(Signature of appellant or representative of appellant)

__________________________

(Name and address of appellant or representative of appellant)

__________________________

(Date)

(Attach Certificate of Service)

Notes

37 Pa. Code § 197.85

The provisions of this § 197.85 adopted May 1, 1981, effective 5/2/1981, 11 Pa.B. 1455; amended August 19, 1983, effective 8/20/1983, 13 Pa.B. 2551.

The provisions of this § 197.85 amended under section 805(b) of the Health Care Facilities Act (35 P. S. § 448.805(b)); and 2 Pa.C.S. § 102(a).

This section cited in 37 Pa. Code § 197.15 (relating to recording of proceedings); 37 Pa. Code § 197.81 (relating to definitions); and 37 Pa. Code § 197.84 (relating to notice of appeal and answer).