Get Certification Statement - Community Health Care Association Of New ... - Chcanys

Filling out the Certification Statement correctly is essential for ensuring compliance with the Community Health Care Association of New York State. This guide provides step-by-step instructions on completing the form online, making the process straightforward for users with all levels of experience.

Follow the steps to successfully complete the Certification Statement online.

1. Click ‘Get Form’ button to access the Certification Statement and open it for editing.
2. Begin by entering the provider name in the appropriate field. Ensure that it matches the legal name associated with the Medicaid provider enrollment.
3. Provide the complete provider address, including street, city, state, and ZIP code. Include a valid telephone number for contact.
4. Fill in the administrator's name and their telephone number, including any necessary extensions. This person is typically responsible for managing the provider's operations.
5. If applicable, enter the billing service name in the specified field. If no billing service is used, leave this section blank.
6. Enter the required 10-digit National Provider ID (NPI), unless exempt. If you are exempt from the NPI, complete the MMIS provider number field instead.
7. Complete the authorized signature section. This requires clear printing of the name, original signature, title, and date of signing.
8. Include a contact person’s name and telephone number. This ensures direct communication regarding the submission.
9. For notarization, ensure the notary public section is completed. The notary must sign and provide their seal, confirming the identity of the signer.
10. Review the entire document for accuracy and completeness. No white-out or red ink should be used, as alterations may lead to rejection.
11. Save your changes, then download, print, or share the completed form as necessary. Ensure the original signed form is mailed to the address provided, as electronic submissions are not permitted.

Complete your Certification Statement online to ensure a smooth and efficient application process.