Compliance and FWA attestation

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* 1. Please Read Carefully

Consistent with CMS requirements, (42 CFR §§ 422.503(b)(4)(vi)(C), 423.504(b)(4)(vi)(C), I attest that I have received and reviewed the following documents.

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* 2. I hereby certify that:
  • I have read, understand and agree to abide by the KS Plan Administrators Code of Conduct and Business Ethics.
  • 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. 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.
  • Unless otherwise noted in the space immediately below, I am not aware of any possible violations of any Federal and/or State laws, regulation, the Code of Conduct or the Anti-Fraud Plan at this time.

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* 3. Conflict of Interest
I 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".

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