Form NYS OMIG CCDRA2010-1 (Revised: 12/30/2009)

Certification of Compliance with DRA

Provider Information

Corporation Name:  , hereinafter "Provider"

Federal Employer Identification Number (SSN IF 1099): 

Provider(s) Covered by this Certification

      Please check this box if the Provider is not enrolled in the NYS Medicaid Program and does not have either a Provider ID or NPI number.
     (NOTE: Continue with Compliance Officer Information.)

      Please check this box if the Provider is not enrolled in the NYS Medicaid Program and add your NPI number(s) below.
     (NOTE: If you erroneously checked this box you may click here to reset.)

Please List the NYS Medicaid Provider Number(s) of all affiliates covered under Provider’s policies and procedures addressing the DRA provisions:

Enter Provider ID:     (Click to add Provider number(s) covered.)

  Count of Provider Numbers entered: 

Compliance Officer Information

First Name:   Middle Initial:   Last Name:   Suffix: 

Title:   Phone Number:   Email Address: 

Certification

 Provider certifies that the provider and its affiliates listed above have established and maintains written policies in accordance with 42 USC § 1396a(a)(68), and includes such policies in any existing employee handbook if maintained by the entity and/or its affiliates, and that they have been properly adopted and published by the provider entity and/or its affiliates, and disseminated among employees, contractors and agents, and that the written policies and any employee handbook shall be retained for a period of six years from the latter of the due date or the actual date of submission of the certification.

Person Certifying

First Name:   Middle Initial:   Last Name:   Suffix: 

Title:   Phone Number: