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I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.?

?I, (print full name of the physician/practitioner), hereby attest that the medical record entry for (date of service) accurately reflects signatures/notations that I made in my capacity as (insert provider credentials, e.g., M.D.) when I treated/diagnosed the above listed Medicare beneficiary.

Attestation is the act of witnessing the signing of a formal document and then also signing it to verify that it was properly signed by those bound by its contents. Attestation is a legal acknowledgment of the authenticity of a document and a verification that proper processes were followed.

Certain types of signatures (e.g., illegible signatures, initials) may require the addition of a ?signature attestation statement? or a signature log to the documentation to ensure the signature's authentication.

Attestation is a kind of testimony or confirmation. It is customary to sign a deed, make a will or sign other written documents in the presence of a witness who also signs the document to attest to its contents and the authenticity of the party's signature.

In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.

I, , as (Title) for (Name of Company), do hereby attest, based upon my best knowledge, information and belief, that the data provided in the Report(s) is accurate, true, and complete.