Get Exhibit 177

Filling out the Exhibit 177, the attestation statement for Federally Qualified Health Centers, is an essential step for entities seeking participation in the Medicare program. This guide provides clear and structured instructions to assist users in completing the form accurately and efficiently.

Follow the steps to successfully complete the Exhibit 177.

1. Click ‘Get Form’ button to obtain the Exhibit 177 form and launch it in the online editor.
2. Begin by entering the name of your entity in the designated field at the top of the form.
3. Review the federal requirements listed, paying close attention to the provision of §1861(aa)(4) of the Social Security Act. You will need to check the appropriate box that corresponds to your entity's status regarding funding and grants.
4. Confirm your entity’s compliance by agreeing to remain compliant with the Federally Qualified Health Center requirements, specified in 42 CFR Part 405 Subpart X and Part 491.
5. Sign the form in the designated signature area, including your title and the date of signing.
6. Fill in the printed name section, ensuring that all requirements are correctly reviewed before finalizing.
7. After completing all sections, you may choose to save your changes, download the completed form for your records, print it, or share it with relevant parties as needed.

Complete your Exhibit 177 form online today to ensure your participation in the Medicare program.