Centers for Medicare & Medicaid (CMS) Compliance Attestation

1. Please read carefully and select the most accurate response below:

To KS Plan Administrators, LLC. dba. KelseyCare Advantage(KCA), I attest that, as an officer of my company, I have the signatory authority to attest on behalf of the company and:

Consistent with CMS requirements, (42 CFR §§ 422.503(b)(4)(vi)(C), 423.504(b)(4)(vi)(C), I attest that all employees, subcontractors, consultants, and volunteers of our company either:

A. Have received and reviewed the following documents from KCA or other similar documents from our organization which meet or exceed the standards of KCA's documents.

or

B. Within 60 days from receipt of this form, will review the following documents received from KCA or other similar documents from our organization which meet or exceed the standards of KCA's documents:

1. KCA's Code of conduct
2. KCA's conflict of interest policy
3. KCA's Training or similar training within the first 90 days of employment has completed all required annual compliance program training, thereafter;
4. Appropriate fraud, waste and abuse education and training to identify, correct, and prevent potential fraud, waste , and abuse within the first 90 days of employment and has completed all other required annual fraud, waste, and abuse training thereafter.