Loading
Form preview picture

Get Attestation Statement

EXHIBIT 127 Rev. 61 Issued 07-23-10 Effective 07-23-10 Implementation 07-23-10 ATTESTATION STATEMENT FOR EXCLUSION FROM PPS FOR FISCAL YEAR BEGINNING DATE Date State Agency Director Name State Agency Name Address City State ZIP Code Dear State Agency Director This attestation must be signed by the Administrator/Chief Executive Officer of the hospital including hospitals with excluded units. ATTENTION Read the following carefully before signing. STATEMENTS OR ENTRIES GENERALLY Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies conceals or covers up by any trick scheme or device a material fact or makes any false fictitious or fraudulent statement or representations or makes or uses any false writing or document knowing the same to contain any false fictitious or fraudulent statement or entry shall be fined not more than 10 000 or imprisoned not more than five years or both. 18 U.S.C. Sec.1001 Based upon my personal knowledge and belief I attest that the responses on the attached prospective payment system PPS exclusion work sheet are true and correct and that name of PPS-Excluded Hospital or Unit currently meets and will continue to meet the applicable requirements for exclusion from PPS for the period beginning first day of hospital s fiscal year as set out in Subpart B of 42 CFR Part 412. I agree that if the hospital or unit fails to meet any of these requirements between the date of attestation and the first day of the hospital s fiscal year I will notify the Regional Office name and address of RO of the change immediately in order to permit a valid determination of distinct part status prior to the beginning of the fiscal year. ATTENTION Read the following carefully before signing. STATEMENTS OR ENTRIES GENERALLY Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies conceals or covers up by any trick scheme or device a material fact or makes any false fictitious or fraudulent statement or representations or makes or uses any false writing or document knowing the same to contain any false fictitious or fraudulent statement or entry shall be fined not more than 10 000 or imprisoned not more than five years or both. 18 U*S*C. Sec*1001 Based upon my personal knowledge and belief I attest that the responses on the attached prospective payment system PPS exclusion work sheet are true and correct and that name of PPS-Excluded Hospital or Unit currently meets and will continue to meet the applicable requirements for exclusion from PPS for the period beginning first day of hospital s fiscal year as set out in Subpart B of 42 CFR Part 412. I agree that if the hospital or unit fails to meet any of these requirements between the date of attestation and the first day of the hospital s fiscal year I will notify the Regional Office name and address of RO of the change immediately in order to permit a valid determination of distinct part status prior to the beginning of the fiscal year.

How It Works

falsifies rating
4.8Satisfied
41 votes

Tips on how to fill out, edit and sign Applicable online

How to fill out and sign Willfully online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Have you been searching for a quick and practical tool to fill out Attestation Statement For Exclusion From Pps at an affordable price? Our platform will provide you with a wide variety of forms that are available for filling out online. It only takes a few minutes.

Stick to these simple instructions to get Attestation Statement For Exclusion From Pps prepared for submitting:

  1. Get the sample you will need in the collection of templates.
  2. Open the template in our online editing tool.
  3. Go through the guidelines to determine which info you will need to include.
  4. Select the fillable fields and include the requested data.
  5. Put the relevant date and place your electronic signature once you fill out all of the boxes.
  6. Look at the form for misprints and other mistakes. In case there?s a necessity to change something, our online editor and its wide variety of instruments are available for you.
  7. Download the new form to your device by hitting Done.
  8. Send the e-document to the parties involved.

Submitting Attestation Statement For Exclusion From Pps does not need to be complicated any longer. From now on easily cope with it from your home or at the workplace right from your mobile device or desktop.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

EXCLUSION FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Attestation Statement For Exclusion From Pps

  • cms
  • cfr
  • falsifies
  • PPS
  • implementation
  • conceals
  • EXCLUSION
  • representations
  • applicable
  • fraudulent
  • ATTEST
  • willfully
  • fictitious
  • medicare
  • medicaid
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.