Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to obtain the form and access it in your preferred online document editor.
2. Begin by entering the hospital information in the specified fields, including the hospital name, MassHealth provider ID, street address, city, state, and ZIP code.
3. Next, input the name of the hospital's CEO and their contact phone number in the designated areas.
4. Review the submission requirements and ensure all relevant data is available, including chart-abstracted measure sets, electronic data files, ICD population data, and medical records for validation.
5. If applicable, indicate measures exemptions by placing an ‘X’ in the blank spaces for the quality measures that do not apply to your hospital for each quarter.
6. Carefully read the certification statement and confirm the accuracy of the information before proceeding to sign the form.
7. Provide the hospital CEO's signature and date it appropriately to complete the attestation.
8. Once all sections are filled out and verified, save the changes you have made to the document. You may choose to download, print, or share the completed form as necessary.

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