Provider Medicare FDR Statement of Attestation
Health First Health Plans, Inc. (HFHP) has entered into a written agreement(s) with you/your medical practice to provide healthcare services to Medicare enrollees, making your organization a First Tier Entity of HFHP.
HFHP and its First Tier, Downstream or Related entities (FDRs) must all comply with the Centers for Medicare & Medicaid Services (CMS) program requirements. This attestation assists HFHP in demonstrating effective communication of these requirements, as well as confirmation of our FDRs compliance with the program requirements.
To gain further understanding of these requirements and ensure they are all met, please visit our FDR Compliance Webpage located at: HF.org/health_plans/fdrattestation/compliance.cfm
Please select your/your medical practice's chosen method of compliance by checking the appropriate boxes and initial where necessary:
INSTRUCTIONS
Visit hf.org/health_plans/fdrattestation/compliance.cfm for resources and information about the responsibilities of an FDR.
- Please read and ensure all requirements are met.
- Under Sections A, B, C and J below, select your chosen answer from the dropdown options.
- Under Sections D through I below, check the corresponding statement to show your agreement with that statement.
- Attach supporting documents as needed.
- Fill in all fields under the “Statement of Attestation” heading.
- Click the “Submit” button.
- Contact the Health First Corporate Compliance Department for assistance if needed. See contact information below.
If you have any questions, please contact:
HFHP Corporate Integrity Department | |
Phone: | 321.434.7496 |
Email: | Integrity@HF.org |
Fax: | 321.434.7545 |
Mail: |
Corporate Integrity ATTN: HFHP Corporate Integrity 6450 US Highway 1 Rockledge, FL 32955 |
Last updated: 9/17/2019