Get Attestation Regarding Monitoring Of Exclusionary Databases Form

Attestation Regarding Monitoring of Exclusionary Databases Pursuant to 42 CFR 455. 101 Section 18. 9 c of the MMC/FHP Contract and per the New York State Department of Health Standard Clauses effective March 1 2011 Section B 9 contained in all MVP contracts MVP is required to obtain an attestation from all provider groups and facilities each a Provider confirming that they have a policy requiring that they monitor all employees staff and agents associated with the Provider against the following exclusionary databases on a monthly basis and that they are performing such monitoring OIG Database http //exclusions. oig. hhs. gov/ System for Award Management www. sam*gov MVP will follow applicable regulatory requirements associated with the disclosure of this information up to and including termination of any contracts with Providers found not to be in compliance with this requirement. Provider Name Provider Address Phone Provider Tax ID Yes I hereby attest on behalf of the above-referenced Provider that such Provider has been or will begin monitoring all employees staff and agents associated with Provider against the exclusionary databases monthly and that the Provider has a policy requiring this monthly monitoring. MVP Health Plan Inc* is collecting this information per the New York State Department of Health Standard Clauses effective March 1 2011 Section B 9 which are part of Provider s contract with information requested may result in denial of a request to participate or where the Provider already participates a termination of its MVP participation agreement. Print or Type the Name of the Person Signing Below Title If Provider is a legal entity the person signing this document on behalf of the Provider hereby warrants that he/she is duly authorized to bind the Provider hereto. Note for Changes of Ownership New Owner or Representative may sign* Signature of Provider or Authorized Representative Date MM/DD/YYYY Name and Phone Number of Person Who Prepared Attestation Fax a copy of this form to your MVP professional relations representative at the fax number listed in the attached letter. oig. hhs. gov/ System for Award Management www. sam*gov MVP will follow applicable regulatory requirements associated with the disclosure of this information up to and including termination of any contracts with Providers found not to be in compliance with this requirement. Provider Name Provider Address Phone Provider Tax ID Yes I hereby attest on behalf of the above-referenced Provider that such Provider has been or will begin monitoring all employees staff and agents associated with Provider against the exclusionary databases monthly and that the Provider has a policy requiring this monthly monitoring. Provider Name Provider Address Phone Provider Tax ID Yes I hereby attest on behalf of the above-referenced Provider that such Provider has been or will begin monitoring all employees staff and agents associated with Provider against the exclusionary databases monthly and that the Provider has a policy requiring this monthly monitoring. MVP Health Plan Inc* is collecting this information per the New York State Department of Health Standard Clauses effective March 1 2011 Section B 9 which are part of Provider s contract with information requested may result in denial of a request to participate or where the Provider already participates a termination of its MVP participation agreement.