KelseyCare Advantage Compliance Attestation Compliance and FWA attestation Question Title * 1. By checking the boxes below, I hereby certify that (Required Responses): Consistent with CMS requirements, (42 CFR §§ 422.503(b)(4)(vi)(C), 423.504(b)(4)(vi)(C), I attest that I have received, reviewed, and understand the following documents: (These documents are readily available for review on the Medicare Compliance webpage of the KS Plan Administrators, LLC d/b/a KelseyCare Advantage (“KCA” website.)•KCA Code of Conduct and Business Ethics and compliance policies and procedures.•KCA Conflict of Interest Policy,•2023 Medicare Parts C & D General Compliance Training, and• 2023 Combating Medicare Parts C & D Fraud, Waste, and Abuse Training (both trainings to be completed within 90-days of employment and annually, thereafter). I have read, understand, and agree to abide by the KCA Code of Conduct and Business Ethics and compliance policies and procedures. I have not been convicted of, or charged with, a criminal offense related to health care, nor have I been listed by a federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health programs. I agree to report suspected violations of any Federal and/or State laws, regulations, the Code of Conduct or the Anti-Fraud Plan to my supervisor or the Compliance Department. Online reporting is available on the Compliance webpage, you can also call our hotline at 713-442-9595. KCA has a no-tolerance policy for retaliation or retribution against any employee who in “good faith” reports suspected or actual misconduct, or violations, including FWA. I understand that any violation of any Federal and/or State laws, regulations, the Code of Conduct, the Anti-Fraud Plan or any other KCA compliance policy or procedure is grounds for disciplinary action, up to and including discharge from employment. I agree to report any instance in which I become convicted, charged with criminal offense, or listed by a federal agency as debarred, excluded or otherwise ineligible for participation. Unless otherwise noted in item 2 (Conflict of Interest) below, I am not aware of any known or possible conflicts of interest, or violations of any Federal and/or State laws, regulations, the Code of Conduct, or participation in FWA activities. I will at least annually complete the KCA Compliance Attestation that accurately reflects potential Conflicts of Interest. I will also disclose any Conflicts of Interest where I, my immediate family (i.e., spouse, parents, siblings and children), and/or members of my immediate household will receive a benefit, gain or something of value. I understand the Conflicts of Interest policy is to supplement good judgement and I will respect the letter and intent of the policy. Question Title * 2. Conflict of InterestI am reporting a conflict of interest so that there may be full disclosure of any current conflict of interest. Please indicate Yes or No below, if Yes you are required to furnish details to the KelseyCare Advantage Compliance department immediately and complete the comment box after clicking "Next". Yes No Next