The attestation form may be completed when the claim documentation under review has an illegible signature. Contractors cannot request or accept an attestation for a late signature or an order that is not signed.
Sample attestation format the following is an example of an acceptable format for an attestation of providerbased compliance.
Medical attestation letter sample. Llc hnfs for these services. You also may have a former coworker or. A letter of attestation is not available for all.
Medical review signature and attestation guidelines for medical review purposes medicare requires that services providedordered be authenticated by the author. Letters must be signed by a physician. The notary seal must be visible.
Cert process for handling a providers allegation of record destruction. You can follow this sample of attestation letter that can be sent to a higher authority to sign and attest for various purposes such as a job or abroad travel of workers or students. Signature attestation statement providers must make every effort to sign documentation before billing a service.
The provider must complete the beneficiary information provide the diagnosis and medical necessity rationale for the requested services or supplies and then sign the letter to attest to the accuracy of the clinical information. In cases where the provider is unable to provide documentation because the needed medical record is completely destroyed due to disaster the provider may submit a disaster attestation letter to that effect. Cms recommends that you place the initial page of the attestation on the official letterhead of the main provider if you elect to use this or any other format.
If youre getting a professional license or applying to sit for an exam you may need to write an attestation letter stating that youve fulfilled the requirements. To ensure compliance with the centers for medicare medicaid services cms policy regarding signature requirements follow the instructions outlined in the cms pub100 08 program. Sample request for attestation letter below briefly describe on sample request for attestation letter.
How to write an attestation letter. Reviewers will not consider attestation statements where there is no associated medical record entry or from someone other than the author of the medical record entry in question even in cases where two individuals are in the same group one should not sign for the other in medical record entries or attestation statements. The title of the physician signing your letter must be underneath the signature.
If you are in a private practicegroup setting you cannot have a partner write a letter of attestation on your behalf. Radiology program director or chief of medical staffno exceptions. Letter of attestation for good character sample by completing this letter i am attesting that i have never been found guilty or pleaded guilty or pleaded no contest regardless of the final outcome to any of the following charges on the attached list under the jurisdiction of louisiana or any other similar jurisdiction of the united states regardless of whether those records have been expunged or sealed.
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