Form NYS OMIG CCSSL2009-1 (Revised: 12/30/2009)

Certification of Compliance with the Social Services Law § 363-d and 18 NYCRR Part 521

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 Compliance Program:

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 adopted, implemented and maintains an effective compliance program that meets the requirements of Social Services Law § 363-d and 18 NYCRR Part 521.

Person Certifying

First Name:   Middle Initial:   Last Name:   Suffix: 

Title:   Phone Number: