Get Part A Provider-based Attestation Statement - Cahaba Gba

Filling out the Part A Provider-based Attestation Statement is an essential process for health care providers seeking to confirm their provider-based status. This guide provides clear and detailed instructions to help users complete the form accurately and efficiently online.

Follow the steps to successfully complete the attestation statement.

1. Press the 'Get Form' button to access the Part A Provider-based Attestation Statement and open it in your preferred editor.
2. Begin by entering the main provider information. Fill in the Medicare provider number, legal business name, and any doing business as (DBA) names. Provide the main provider's complete address, including city, state, and ZIP code.
3. Next, input the attestation contact information. This includes the contact name and phone number. Ensure that this information is legible and accurate for any follow-up communication.
4. Complete the provider-based facility information section. Include the facility's Medicare provider number, legal business name, DBA name, and exact physical address. Be thorough, as this information is critical for identification.
5. Indicate whether this attestation is adding, deleting, or changing previous information. If so, include the effective date of the changes for clarity.
6. Specify whether the facility is on-campus or off-campus. Provide a detailed map, if necessary, to validate the distance from the main provider to the facility.
7. Carefully read and initial the attestation certification options regarding compliance with federal regulations for on-campus or off-campus statuses.
8. Proceed to complete all required attestations concerning departmental and operational integration between the provider and the facility. Answer 'Yes' or 'No' to each requirement as specified in the form.
9. Review the entire form to ensure all information is accurate and complete. Make any necessary edits before finalizing.
10. Once completed, save your changes, and if applicable, print or share the form according to your needs. Ensure the original signature from an authorized person is included for submission.

Complete your Part A Provider-based Attestation Statement online today to ensure compliance and maintain your provider status.