Covered Entity Name:
Address: City, State, Zip Code:
FEIN (9 digit number with no '-'):
Compliance Period: Calendar Year beginning January 1, (YYYY):
I hereby attest that, as a condition for the above-identified Provider Entity to receive payments under the Ohio Medicaid program, I have read Section 6032 of the Deficit Reduction Act of 2005 and confirm that:
The Provider Entity's written policies and procedures contain detailed information about:
  • The False Claims Act established under Sections 3729 through 3733 of Title 31 of the Code of Federal Regulations;
  • Administrative remedies for false claims and statements established under Chapter 38 of Title 31 of the United States Code (U.S. Code);
  • Any State laws pertaining to civil or criminal penalties for false claims and statements under Ohio Revised Code (R.C.) Sections 5164.35, 2913.40, and 2913.401; and
  • Whistleblower protections (R.C. 4113.51–4113.52).
The Provider Entity's written policies and procedures also contain detailed information regarding its own policies and procedures to detect and prevent fraud, waste, and abuse in Federal health care programs, as defined in 42 U.S. Code 1320a-7b(f), in relation to the Ohio and Federal laws referenced above.
The Provider Entity must provide copies of its written policies to:
  • Its employees (including management); and
  • Any of its contractors and agents.
The Provider Entity's written policies and procedures are included in any employee handbook maintained by the Provider Entity. I possess all necessary powers and authority to execute and make the representations contained in the Attestation of Compliance on behalf of the Provider Entity.
I understand the statements made in this Attestation are subject to scrutiny and may be subject to civil and criminal penalties from the Ohio and Federal laws referenced above.
Print Name:
Email Address (must be valid for receipt):
This certifies that all Medicaid Provider IDs and Service Locations associated with this SSN/FEIN are in compliance with Section 6032 of the Federal Deficit Reduction Act.