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Palmetto GBA PROVIDER-BASED ATTESTATION STATEMENT In order for a facility to be designated as provider-based for billing and payment purposes it must meet the applicable requirements set forth by Centers for Medicare Medicaid Services CMS in Title 42 Code of Federal Regulations CFR 413. 65. If you believe your facility meets the criteria as a providerbased facility please submit the attestation statement to Palmetto GBA at the following address.

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