FDR Compliance Attestation

The Compliance Attestation form is used to confirm that the FDR or Affiliate is in compliance with VA Premier FDR and Affiliate Compliance Policy for the Commonwealth Coordinated Care program.

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Attestation*
- I certify, as an authorized representative having responsibility directly or indirectly for all employees, contracted personnel, providers/practitioners, and vendors who provide health care or administrative services under Medicaid and/or Medicare, that the statements above are true and correct to the best of my knowledge.
- In addition, my organization agrees to maintain supporting documentation for a period of ten (10) years and will furnish evidence of the above to VA Premier CompleteCare upon request for monitoring and auditing purposes.
* Indicates a required field
Name of Organization*
Taxpayer Identification No. (TIN)*
NPI
Name*
First Last
Title*
Phone Number*
Email Address*
Additional Comments
Electronic Signature: Please type your full name. By typing your name, you are signing this Compliance Attestation electronically. You agree your electronic signature is the legal equivalent of your handwritten signature.*
Date
Date Format: MM slash DD slash YYYY

Notice:
Please print a copy of this page for your records. Thank you. {all_fields}
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 3

First Tier, Downstream, or Related Entity (FDR) and Affiliate Compliance Attestation

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