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ATTACHMENT II <br /> Page 1 of 2 <br /> DATA FOR DUPLICATE PA�'MENT PLAN <br /> Listed below are the data that each Settling Plan will send to HCFA in satisfaction of its <br /> obligations under the Duplicate Payment Plan set out in Paragraph E of the Agreement, <br /> incorporated into the Agreement by Reference in Paragraph E(2). <br /> • Settling Plan number <br /> • Settling Plan name <br /> • Provider total charges <br /> • Amount covered by Settling Plan <br /> • Date Settlir.g Plan made payment <br /> • Total Allowed chazge <br /> • Indicator of whether payee is the provider or the beneficiary <br /> 1 <br /> • Name and address of party receiving payment <br /> • Begin Date of Service � <br /> • End Date of Service <br /> • Type of Service <br /> , <br /> • Provider identification number ; <br /> i <br /> , <br /> • Provider Type � <br /> • Provider tax identification number <br /> • Provider name of facility I <br /> � <br /> � <br /> • Provider name of physician � <br /> • Provider address <br /> i <br />