2017 Provider Attestations Question Title * 1. Upon hire (before start date) and monthly thereafter, all employees are screened against federal exclusion lists to ensure eligibility to participate in federal health care programs. Yes No Question Title * 2. If an employee is determined to be excluded, they are immediately removed from participation in federal health care programs, and Network Health’s contract manager will immediately be notified if the provider/employee has provided services to any Network Health member. Yes No Question Title * 3. Upon hire (within 90 days) and annually thereafter, all employees have done the following. Check all that apply. Completed general compliance and privacy training. Completed the Centers for Medicare and Medicaid Services (CMS) fraud, waste and abuse (FWA) training directly on the Medicare Learning Network’s page or from the link located on Network Health’s website. Received your organization’s conflict of interest policy and are expected to disclose any conflicts of interest to you. Received your organization’s Standards of Conduct document and have acknowledged receipt and understanding of the document Question Title * 4. I agree to provide training logs and certificates of completion upon request to Network Health to validate training has been completed (Medicare requires these training logs to be retained for a period of no less than 10 years). Yes No Question Title * 5. Employees have access to the following. Check all that apply. Reporting mechanisms which can be used to report instances of non-compliance and/or FWA. At least one method of reporting instances of non-compliance and/or FWA that can be used to report anonymously. At least one method or reporting instances of non-compliance and/or FWA that is available 24 hours/day, 7 days a week. Question Title * 6. Upon the initial visit and annually thereafter, patients are provided with the required HIPAA notice. Yes No Question Title * 7. Does your office conduct general compliance and Health Information Accountability and Portability Act (HIPAA) training for all employees upon hire and annually thereafter? Yes No Question Title * 8. Patients are provided with the required financial policy upon the initial visit and annually thereafter. Yes No Question Title * 9. I agree to notify my Network Health contract manager of any provider additions, terminations and/or changes within 30 days of becoming known. Yes No Question Title * 10. Notes/Comments regarding responses above. Question Title * 11. Please provide the name of your practice and the name and contact information of the individual completing this form. Next
